effective leadership in nursing essay

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Leadership in Nursing: Qualities & Why It Matters

4 min read • May, 19 2023

Strong leaders in nursing are vital to help navigate the constant evolution of health care. Nurse leaders do more than balance costs, monitor productivity, and maintain patient and staff satisfaction. They serve as role models and influence health care organizations at all levels. A strong nurse leader motivates their colleagues, setting the tone for a safe, civil workplace with a culture of high morale and job retention.

What Is a Nurse Leader?

A nurse leader is defined by their actions, and not always by a position of authority. Leaders in nursing inspire and influence others to achieve their maximum potential. They use applied leadership in nursing by drawing upon critical thinking skills to manage a team.

Nurse leaders take a broad view of how daily tasks impact the overall goals of the health care organization. They communicate expectations to their team and motivate them to achieve predetermined goals. Nurses can lead from various organizational areas if they project the necessary leadership qualities to influence others.

Leadership Qualities in Nursing

A nurse leader role combines essential nursing, business, and leadership skills developed through ongoing learning . They must be flexible enough to adapt to technological changes, fluctuating payment methods, new treatment modalities, and regulatory and legislative environments. Critical skills for effective nursing leadership include:

Communication and Collaboration : These skills can reduce miscommunication, encourage shared decision making, and provide a sense of working together toward common goals.
Education and Quality of Practice : Continued professional development allows leaders in nursing to keep pace with the ever-changing health care environment while striving for excellence by supporting quality, evidence-based practice.
Environmental Health and Resource Utilization : Leadership in nursing ensures that patient care can be provided effectively in a safe and healthy environment while promoting wellness among all health care staff.
Ethics and Professional Practice Evaluation : Influential nurse leaders model ethical practices to guide decisions, display honesty by being accountable for their actions, and evaluate their adherence to professional practice standards. Learn more about the Code of Ethics for Nurses .
Professionalism and Leadership : Leaders in nursing build vital relationships and collaborate with various health care teams on sensitive topics. Using critical thinking skills allows those in nursing leadership roles to analyze decisions impacting the organization. They then clearly explain the rationale in a manner that encourages staff support.

Other nursing leadership skills, such as displaying compassion and empathy, can assist the nurse leader in developing interpersonal relationships and gaining respect in their role.

7 Leadership Styles in Nursing

Nursing leadership styles can impact job satisfaction , nurse retention rates , quality of care, and patient outcomes . The nurse’s educational background, personality, and work environment may influence their nursing leadership style. Each type of nurse leader role can be valuable when utilized in the right setting.

The Transformational nurse leader works to inspire nurses to achieve a greater vision by helping with strength development. This nursing leadership style works well with mentoring.
The Autocratic nurse leader makes quick decisions with little input from employees and excels at task delegation. This nursing leadership style may be most effective in an emergency.
A Laissez-faire leadership style puts faith in every facet of a well-oiled machine. This method may work well with experienced teams or self-directed nurses.
The Democratic nurse leader is collaborative and focuses on team success. This nurse leader might excel in quality improvement roles but may not be effective in situations requiring independent decisions.
The Servant nurse leadership style focuses on employee development and individual needs. This method works well with goal-driven environments or as a nurse educator.
The Situational leadership style is the most adaptable since it analyzes the situation and determines the appropriate approach. This nurse leader is flexible enough to modify their approach based on the organization or individual’s needs. This style works well with nursing students but may divert from the organization’s long-term goals.
The Transactional nurse leader does well with short-term goals by focusing on efficiency and performance. This task-oriented style reduces errors and works well with tight deadlines.

Examples of Leadership in Nursing

Projecting leadership skills in nursing that influences others can allow a nurse to lead without being assigned a specific leadership position. The aspiring nurse leader might:

Seek out a mentor or become one
Volunteer for committee roles
Become involved in the community
Take educational courses
Stay current on the latest health care trends
Get involved with public policy

A nurse aspiring for a nursing leadership role can get a certification or obtain additional degrees specific to nursing leadership to increase their knowledge base and expand upon professional development. But a title and the education aren’t enough to create an effective leader. Nurses and other health care staff need to believe their contributions make a difference in the organization.

Why Is Nurse Leadership Important?

Nurse leaders make a difference in workplace culture and drive positive changes in health care legislation. When a team admires the qualities of their leader, it boosts morale and promotes a psychologically safe workplace, which leads to higher job satisfaction and retention rates. Influential leaders in nursing ensure that the organization's vision is communicated to the nursing staff while mentoring the nursing leadership of tomorrow .

Explore courses, webinars, and other nursing leadership and excellence resources offered by ANA .

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The essentials of nursing leadership: A systematic review of factors and educational interventions influencing nursing leadership

Affiliations.

1 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada. Electronic address: [email protected].
2 Department of Nutrition, Dietetics and Food, School of Clinical Sciences at Monash Health, Monash University, Level 1, 264 Ferntree Gully Rd, Notting Hill, VIC 3168, Australia.
3 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada.
4 Faculty of Nursing, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada; Technical High School of Campinas, State University of Campinas (UNICAMP), Barão Geraldo, Campinas - São Paulo 13083-970, Brazil.
PMID: 33383271
DOI: 10.1016/j.ijnurstu.2020.103842

Background: Nursing leadership plays a vital role in shaping outcomes for healthcare organizations, personnel and patients. With much of the leadership workforce set to retire in the near future, identifying factors that positively contribute to the development of leadership in nurses is of utmost importance.

Objectives: To identify determining factors of nursing leadership, and the effectiveness of interventions to enhance leadership in nurses.

Design: We conducted a systematic review, including a total of nine electronic databases.

Data sources: Databases included: Medline, Academic Search Premier, Embase, PsychInfo, Sociological Abstracts, ABI, CINAHL, ERIC, and Cochrane.

Review methods: Studies were included if they quantitatively examined factors contributing to nursing leadership or educational interventions implemented with the intention of developing leadership practices in nurses. Two research team members independently reviewed each article to determine inclusion. All included studies underwent quality assessment, data extraction and content analysis.

Results: 49,502 titles/abstracts were screened resulting in 100 included manuscripts reporting on 93 studies (n=44 correlational studies and n=49 intervention studies). One hundred and five factors examined in correlational studies were categorized into 5 groups experience and education, individuals' traits and characteristics, relationship with work, role in the practice setting, and organizational context. Correlational studies revealed mixed results with some studies finding positive correlations and other non-significant relationships with leadership. Participation in leadership interventions had a positive impact on the development of a variety of leadership styles in 44 of 49 intervention studies, with relational leadership styles being the most common target of interventions.

Conclusions: The findings of this review make it clear that targeted educational interventions are an effective method of leadership development in nurses. However, due to equivocal results reported in many included studies and heterogeneity of leadership measurement tools, few conclusions can be drawn regarding which specific nurse characteristics and organizational factors most effectively contribute to the development of nursing leadership. Contextual and confounding factors that may mediate the relationships between nursing characteristics, development of leadership and enhancement of leadership development programs also require further examination. Targeted development of nursing leadership will help ensure that nurses of the future are well equipped to tackle the challenges of a burdened health-care system.

Keywords: Interventions; Leadership; Nursing workforce; Systematic Review.

PubMed Disclaimer

Targeting personalised leadership factors based on the organisational needs of nurses may cultivate and improve their nursing leadership. Singh S, Kapoor S. Singh S, et al. Evid Based Nurs. 2022 Apr;25(2):68. doi: 10.1136/ebnurs-2020-103385. Epub 2021 Aug 18. Evid Based Nurs. 2022. PMID: 34407986 No abstract available.

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How leadership matters

Clinical nurses' perceptions of leader behaviors affecting their work environment.

Raso, Rosanne DNP, RN, NEA-BC, FAAN, FAONL; Fitzpatrick, Joyce PhD, MBA, RN, FAAN, FNAP

Rosanne Raso is the editor-in-chief of Nursing Management and the vice president and CNO at NewYork-Presbyterian/Weill Cornell in New York, N.Y. Joyce Fitzpatrick is the director of the Marian K. Shaughnessy Nurse Leadership Academy and Elizabeth Brooks Ford professor of nursing at Case Western Reserve University Frances Payne Bolton School of Nursing in Cleveland, Ohio.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

For 131 additional nursing continuing professional development articles related to management topics, go to NursingCenter.com/CE .

What should nurse leaders do to ensure a healthy work environment? This article presents positive and negative leader attributes in the words of clinical nurses and actions you can take to boost your relational leadership competencies.

What should nurse managers and leaders do to ensure a healthy work environment for clinical nurses? What we know is that relational styles of leadership have been studied in nursing for years and are consistently associated with positive workforce outcomes. 1,2 Relational leadership is built on solid relationships with direct reports and individuals from other disciplines, as its name implies. This type of leadership is positive, particularly in nurturing employee engagement and healthy work environments. Mastering the skills of interpersonal engagement and creating trust and influence through connections are hallmarks of great nurse leaders. 3 Yet, even though there's considerable support for relational leadership, there are still gaps in the implementation of programs to develop nurse leaders. Developmental programs for nurse managers often focus on the management skills needed, such as finances, budgeting, and resource allocation and procurement, creating a significant gap in preparation related to the development of relational leadership competencies.

From a qualitative perspective, we were interested in determining what clinical nurses describe as positive and negative leadership behaviors that affect their work environment. In this article, we present our findings in the words of clinical nurses, along with implications for nurse leaders seeking to understand the impact of clinical nurses' perceptions of their supervisors' actions, especially their relational leadership competencies.

Relational leadership is based on positive psychology, which focuses on helping people find meaning and purpose, live meaningful lives, and search for personal strength and value. 4 Therefore, relational leadership is grounded in optimism, integrity, positive emotions, and employee growth and development. The link to nursing leadership is obvious—ethics, positive change, purpose, growth, and social connection are all part of who we are as nurses and nurse leaders.

The most common relational leadership styles are transformational, authentic, and servant. All three leadership styles have connections to healthy work environments and staff engagement, which, in turn, provide the foundation for positive workforce and patient outcomes. 5,6 (See Figure 1 .) To add empirical support to these connections, we previously conducted two research studies on authentic nurse leadership and its relationship with a healthy work environment, expecting a positive relationship. In both studies, we found a significant positive relationship, providing empirical evidence that authentic nurse leadership is a standard for a healthy work environment. 7,8

We used Giordano-Mulligan and Eckhart's authentic nurse leadership model in our studies. This model has three main domains with five subcomponents or attributes: personal integrity to include moral-ethical courage and self-awareness, transparency to include relationship integrality and shared decision-making, and altruism to include caring. 9 These attributes were found to be important for nurse engagement. Caring was identified as an integral attribute that nurses seek in their leaders, which makes this one of the first nursing leadership models with caring science embedded in the practice. 10 (See Table 1 .)

Domains	Attributes
Personal integrity	Moral-ethical courage Self-awareness
Transparency	Relational integrality Shared decision-making
Altruism	Caring

We also used the American Association of Critical-Care Nurses' (AACN) healthy work environment model, which is evidence-based and relationship-centered and includes six standards: skilled communication, true collaboration, effective decision-making, authentic leadership, meaningful recognition, and appropriate staffing. All six elements are considered essential, meaning that missing any one of them won't result in a sustainable healthy work environment. 11 (See Figure 2 .)

This study received Institutional Review Board approval. Participants were recruited at the 2019 American Nurses Credentialing Center National Magnet ® Conference. Two open-ended questions were asked after quantitative and demographic questions in an anonymous survey:

How does your manager positively affect your work environment?
How does your manager negatively affect your environment?

What did clinical nurses say?

Four-hundred and fifty-six open-ended comments were collected, split between positive (n = 245) and negative (n = 211) from a final sample of 254 clinical nurses. Eighty of the “negative” comments were either blank or positive rather than negative. Most respondents practiced in critical/progressive care (27%) and adult medical-surgical (26%) areas on the day shift (77%). The responses revealed behaviors that clinical nurses valued and criticized in their managers, which trended into several categories.

For positive comments, the top trends were related to relational skills, such as communication, positivity, and approachability (n = 87); caring and professional growth (n = 68); visibility (n = 57); and advocacy (n = 10), aligning with both authentic nurse leadership attributes and healthy work environment standards. There were 10 comments about flexible scheduling. (See Table 2 .)

Positive trend	Authentic nurse leadership attribute	Healthy work environment standard
Visibility and presence	Self-awareness	Authentic leadership
Flexible scheduling		Appropriate staffing
Transparent communication	Relational integrality	Effective communication
Provides assistance	Self-awareness	True collaboration
Encourages involvement	Shared decision-making	Effective decision-making
Compassionate, kind, supportive	Caring
Approachable, open minded, listens	Shared decision-making	Effective decision-making
Positive	Relational integrality	Authentic leadership
Advocacy	Moral-ethical courage	Authentic leadership
Encourages professional growth	Caring	Meaningful recognition
Recognizes staff	Relational integrality	Meaningful recognition

In the words of clinical nurses, positive leadership attributes included:

“By inspiring me to be my best.”
“When I see her, she's supportive and responsive to my concerns. She has asked me to be a part of various committees to further my career development.”
“She's very approachable and is an active listener.”
“She's concerned for my well-being as a person.”
“She's very involved in encouraging advancement and uplifting her staff.”
“Listens and takes suggestions/concerns seriously.”
“She uses open communication at all times in all situations.”
“Sends out a bulletin every Friday that's helpful for keeping up with nursing news and hospital updates.”
“She fights for us on a daily basis.”

For negative comments, the top trends were lack of presence and caring (n = 28), lack of follow-through and open-mindedness (n = 18), lack of visibility/unapproachable (n = 16), and inadequate communication (n = 11). There were seven negative comments about staffing and scheduling. (See Table 3 .)

Lack of visibility and presence

Unprofessional

Micromanager

Doesn't help

No follow-through

Judgmental, not open to suggestions

Unapproachable

Negative attitude

Plays favorites, biased

Makes emotional decisions

Inadequate communication

In the words of clinical nurses, negative leadership attributes included:

“The overall feeling on our unit is that our managers need to communicate more effectively.”
“She isn't always approachable and cares about budget more than staff wellness.”
“She doesn't always notice work I've done.”
“The manager focuses only on problems.”
“Night shift workers are unfortunately neglected.”
“She's judgmental. Has a hard time taking our opinion into consideration. She makes decisions without consulting us.”
“Doesn't have confidence in self and, therefore, doesn't instill confidence in staff.”
“Is too scattered, starts many things without finishing. Lacks follow-through and accountability.”

These qualitative results with a vast majority of positive comments aren't surprising considering our previous empirical findings that both authentic nurse leadership and healthy work environments were present in the national prepandemic sample of clinical nurses. In the second, midpandemic study in the summer of 2020, we also found that authentic nurse leadership was present in a much larger sample, signaling that nurse leaders throughout the country demonstrate authentic attributes as noted by their direct reports, even in a crisis. 8 Finding many more positive comments than negative points to the same conclusion about the overarching presence of sound nursing leadership.

Because the top positive trends were related to communication skills, caring, professional growth, and visibility, we understand what aspects of leadership are important to clinical nurses. It isn't their leaders' nursing acumen or clinical skills, although being able to help was mentioned several times. It isn't a perfect schedule or staffing, although flexible scheduling was brought up, albeit infrequently. Rather, it's about the alignment of relational competencies, authentic nurse leadership attributes, and healthy work environment standards. Clinical nurses want to be heard, receive honest information, be supported by a visible leader, grow, and be recognized. Values-driven leadership, shown in the comments on advocacy and “fighting” for staff, is integral for the authentic nurse leadership attribute of moral-ethical courage. We believe that nurse managers aspire to be this type of leader.

The negative behavior trends were consistently the opposite of the positive ones. Lack of presence, communication, recognition, follow-through, and collaborative decision-making are noticed and can contribute to disengagement. Staffing and scheduling were only occasionally mentioned, which was surprising considering there wasn't agreement that appropriate staffing was present in the rating of healthy work environment standards. Perhaps clinical nurses consider staffing to be out of the scope of the frontline manager and more of an organizational issue.

The attribute of caring in the authentic nurse leadership model, with its concomitant depiction as nurturing, compassionate, kind, and personally interested, was frequently mentioned and important to clinical nurses, further supporting this relatively new framework for nursing leadership. This attribute isn't specifically included in the healthy work environment standards, although the standard of meaningful recognition certainly includes professional growth and feeling valued for your contributions.

Implications for nurse managers

The link between relational leadership and nursing values, such as ethical practice, positive change, purpose, growth, and interpersonal connections, was evident in our findings, as was the association with healthy work environments and staff engagement—the foundation for positive patient outcomes. Nurse leaders must remove the barriers to relational, authentic, and visible leadership. Covering two geographically separate units, being inundated with meetings and tasks, or not having a frontline leader at all impacts clinical nurses' perceptions of leadership support. Making this case to senior leaders is imperative when decisions are being made about frontline leaders' scope and responsibilities.

Effective communication and meaningful recognition are practices we can all do, and structures are needed to support them. Regarding communication, you must get information first, which may be challenging, and share it in as many formal and informal ways as you can (verbal, written, posted, emailed, cascaded), with night supervisors on the same page. Shared governance structures can be effective not only for decision-making, but also communication. 12 If you think you've communicated enough, do it again. As a human resource colleague often implores, get the message out seven times in seven different ways.

Recognition is the same—there's never enough. Do you get tired of being recognized for your value? Of course not. Structured mechanisms include daily shout-outs, bulletin boards, “random acts of kindness” programs, DAISY awards, employee of the week/month, Nurses Week activities, thank-you cards, leader rounds, and numerous other ideas. Leaders must make recognition as important as any other responsibility in the job description. 13

Our obligation to teach and learn relational behaviors, authentic nurse leadership attributes, and healthy work environment standards and how to build and demonstrate them is another implication. Effective leadership development occurs through experiential learning, as well as didactic mechanisms. 14 This applies to aspiring leaders, clinical leaders, and formal leaders.

Leadership matters

Our clinical nurses have spoken. The importance of relational competencies, caring behaviors, and visibility is evident. Relational leadership is even more critical as we continue to be challenged through our second year of the pandemic. This type of leadership alone isn't enough to create a healthy work environment for clinical nurses; nevertheless, it's required. We're all obligated to be present and lead with integrity, caring, and transparency. Leadership matters.

INSTRUCTIONS How leadership matters: Clinical nurses' perceptions of leader behaviors affecting their work environment

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Evidence and practice

Developing effective nurse leadership skills, denise major deputy director of nursing, salisbury nhs foundation trust, salisbury, wiltshire, england.

• To enable you to outline the various types and characteristics of leadership

• To understand the importance of effective nurse leadership and its effect on patient care

• To identify ways to enhance your leadership skills and apply these in your everyday practice

Leadership is a role that nurses are expected to fulfil, regardless of their job title and experience. Nurses are required to lead and manage care as soon as they have completed their training. However, the development of leadership skills and the associated learning can be challenging, especially for less experienced nurses and those at the beginning of their careers. This article examines the importance of effective leadership for nurses, patients and healthcare organisations, and outlines some of the theories of leadership such as transformational leadership. It also details how nurses can develop their leadership skills, for example through self-awareness, critical reflection and role modelling.

Nursing Standard . doi: 10.7748/ns.2019.e11247

Major D (2019) Developing effective nurse leadership skills. Nursing Standard. doi: 10.7748/ns.2019.e11247

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@denisemajor4

[email protected]

None declared

Published online: 07 May 2019

clinical leadership - leadership development - leadership frameworks - leadership models - leadership skills - transformational leadership

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‘Nursing Times wants to ensure that the voices of nurses and midwives are heard’

STEVE FORD, EDITOR

You are here: Leadership

Good leadership in nursing: what is the most effective approach?

17 July, 2017

Good leadership in nursing is likely to draw on different theories according to the task at hand, the team’s needs and the local circumstances. This article comes with a handout for a journal club discussion

There is no simple answer to the complex question of what makes good leadership in nursing, despite the existence of evidence showing that it can have a positive impact on both patient experience and outcomes, and nurse satisfaction and retention. This article outlines different leadership theories, describing how they can be applied to nursing and how effective they are. What emerges is that different approaches are needed according to what leaders set out to achieve. One thing is certain: success hinges on good relationships between leaders and teams.

Citation: Maxwell E (2017) Good leadership in nursing: what is the most effective approach? Nursing Times [online]; 113: 8, 18-21.

Author: Elaine Maxwell is associate professor in leadership, School of Health and Social Care, London South Bank University.

This article has been double-blind peer reviewed
Scroll down to read the article or download a print-friendly PDF here
Download the Nursing Times Journal Club handout here to distribute with the article before your journal club meeting

Introduction

What is the best approach to nurse leadership – if there is such a thing? What evidence is there on the effectiveness of different leadership styles? Despite overwhelming interest in leadership within the profession, there is surprisingly little evidence about what actually works, and much of the narrative is based on received wisdom or personal experience.

Researching leadership is challenging, as there is no direct link between the actions of leaders and their outcomes. Instead, leadership is one of a number of factors that make up the context in which groups of people work. This complexity means there is no ‘one size fits all’ answer to what makes good leadership in nursing.

Transactional or transformational?

There has been great interest in the contrast between transactional and transformational leadership following the work of Burns (1978). Transactional leadership is a behavioural model where leaders ensure that work is completed through either reward or sanction, whereas transformational leadership is a motivational model where leaders seek to trigger motivation in individuals rather than get them to undertake a particular task. Bass and Avolio (1990) describe transformational leadership as the four ‘i’s:

Individualised consideration – identifying the needs of individual members of staff;
Intellectual stimulation – question the status quo and present new ideas;
Inspirational motivation – present a vision in which people can achieve their personal goals through meeting the organisation’s goals;
Idealised influence – role model the behaviours.

Burns’ original work is often presented rather crudely as a stark choice between transactional and transformational leadership, where the former is portrayed as bad and the latter as good. However, in the real world, it is harder to distinguish between the two. Avolio and Bass (1995) found that transformational leadership is more common at senior levels of the hierarchy than at the sharp end of getting the work done. Judge and Piccolo (2004) suggest that even transformational leaders use contingent rewards at times. This suggests that the choice of leadership style depends on the task at hand – it could be as dangerous to be a wholly transformational leader as it is to be a wholly transactional leader.

New ways of thinking

What does this mean for nursing? Hutchinson and Jackson (2013) argue that the flaws in how transformational leadership has been researched in nursing mean that “new ways of thinking about nursing leadership within complex dynamic systems are required”. Although these flaws are not described, they might be the use of cross sectional surveys of nurses’ perceptions of the leader’s style and comparing that with nurses’ satisfaction with their jobs.

This is borne out with counterintuitive research findings. Kvist et al (2013) explored the link between transformational leadership and empirical outcomes for patients and nurses. None of the nurse leaders they studied scored highly on the subscales of transformational leadership. However, patient satisfaction was reported to be excellent and patients rated nurses’ professional practice highly. Nurses evaluated their own professional skills as excellent and felt their leaders’ support for professional practice was good.

As Wong (2015) explains, claims have been made that both transformational and resonant leadership (defined later in this article) reduce patient mortality rates but through different mechanisms. Wong also found that transactional leadership can increase patient satisfaction, suggesting that there is no single ‘best’ leadership style.

There is evidence to suggest that nurse leadership has a significant impact in two main areas: patient experience and outcomes, and nurse satisfaction and retention. There is some suggestion that the latter then influences the former. However, determining what makes good nurse leadership is challenging.

In the face of ambiguity and complexity, it seems that good leadership is nuanced and requires careful consideration. Where there are apparently contradictory findings, it is important to go deeper and see what apparently different approaches have in common.

You cannot enforce leadership

Traditionally, leadership studies have focused on the beliefs and actions of leaders, leaving followers with merely a passive role and entirely at the whim of leaders. Recent studies have explored the roles of both leaders and followers, and suggest that it is the nature of the relationship between them, rather than any specific behaviours of leaders, that produces effective leadership.

Hersey and Blanchard (1969) observed that the leader’s actions should be determined by the maturity of the team and that the behaviours of good leaders are situational rather than fixed. Leaders in this model assess the needs of the followers and adapt their actions accordingly.

Haslam et al (2011) suggest that leaders must be an integral part of the team, and that their main role is to create a sense of group identity. The leader must articulate what the team values are and why people would want to be part of it, and motivate followers to identify with the group, engendering a sense of loyalty.

Uhl-Bien et al (2014) go further, suggesting that the leadership of a team is co-produced with followers, and that it depends on their behaviours toward the leader and the leader’s behaviours towards them, in a virtuous circle. The idea is that you cannot enforce leadership and that it is a gift from followers. In this model, there is a distinction between people in positions of authority and leaders, and leadership has to be developed rather than assumed.

A plethora of models

In the models described by both Haslam et al (2011) and Uhl-Bien et al (2014), successful leadership is achieved by articulating common goals rather than by leaders presenting their vision. Looking at the attitudes and responses of individuals in isolation is not sufficient – leaders must create a collective motivation that all staff identify with. This school of thought has led to a plethora of models, including West et al’s (2014) collective leadership, Gronn’s (2002) distributed leadership, Uhl-Bien et al’s (2014) complexity leadership, and Haslam et al’s (2011) social identity leadership – to name but a few.

Avolio, who had worked with Bass on transformational leadership, developed his thinking further into authentic leadership, which emphasises the leader’s ethics and behavioural integrity (Avolio et al, 2004). This is reflected in Haslam’s model, which requires the leader to lead by example, displaying the team’s values and desired behaviours (Haslam et al, 2011). What these theories have in common is a focus on collegiate relationships that leaders form with, and promote between, other members of the team.

In contrast to transformational leadership, which can be criticised for being very leader focused, resonant leadership is described by Goleman et al (2002) as a type of leadership that invests time and effort into creating good relationships rather than into setting an inspiring vision. Depending on the situation, the vision and objectives can be coproduced or team members can operate autonomously, reflecting Hershey and Blanchard’s situational leadership model.

Impact on patient outcomes

There is some evidence that resonant leadership has a positive impact on patient outcomes. Cummings et al (2010) studied nursing leadership in nine acute hospitals in Canada, collecting nurses’ perceptions of their leaders, whose styles ranged from highly resonant to highly dissonant. They found that the differences in leadership styles explained 5.1% of the variance in 30-day mortality rates between hospitals.

Similarly, Paquet et al (2013) found that good relationships between leaders and staff were associated with decreased medication errors and reduced length of stay. Vogus and Sutcliffe (2007) found that one of the outcomes of resonant leadership – trust – was a factor in the success of a project to reduce the incidence of medication errors. Given the team nature of nursing – nurses rarely act completely on their own – some studies have suggested that good outcomes are seen when nurse leaders focus on facilitating effective teamwork. Anderson et al’s (2003) study of US care homes showed that:

The level of registered nurse participation in clinical decision-making accounted for 15% of the variance in clients’ aggressive and/or disruptive behaviour problems;
The level of transparency accounted for 21% of the variance in use of restraints;
The degree to which leaders focused on relationships accounted for 11% of the variance in the prevalence of fall-related fractures.

Relational leadership was found to be associated with patient satisfaction by Kroposki and Alexander (2006). In contrast, Havig et al (2011) found a significant positive association between a task-oriented leadership style of nursing home ward managers and the families’ satisfaction with resident care. Doran et al (2004) found that a transactional leadership style was related to increased patient satisfaction, proposing that transactional approaches may facilitate patient care by providing the team with direction, defined tasks and clear expectations.

In reality, these findings may be better explained by the fact that the needs of patients are every bit as important as the needs of staff. Sometimes work that does not inspire staff needs to be done for patient safety or cost-efficiency reasons, which may well involve a transactional approach. Furthermore, relational and transactional approaches may not be mutually exclusive. An effective leader should be able to both maintain good relationships with the team and ensure that key tasks are done.

Impact on nurse satisfaction

There is a body of evidence indicating that nurse leadership styles have a strong influence on nurse morale and retention. Retention is an integral part of safe staffing, and good collegiate relationships between nurses and nurse leaders that increase retention may explain the impact of leadership style on patient outcomes; this could also provide an explanation for Park et al’s finding that a high nurse turnover cancelled the effect of increasing the total number of registered nurses on a ward (Park et al, 2012).

The evidence around nurse satisfaction and retention draws on the seminal work by Herzberg et al (1959) around the motivation to work. They proposed that the reasons for job satisfaction are intrinsic – that is, based on how the job makes workers feel. However, the reasons for dissatisfaction are extrinsic – for example, dissatisfaction with the material rewards that come with the job. Job satisfaction, they claim, is linked to empowerment and a sense of achieving personal and professional goals, and while low pay can create dissatisfaction, raising it does not create a sense of satisfaction with the job.

This distinction is reflected in the work of Veld and Van de Voorde (2014), who found that the work environment –including leadership – affected nurses’ work commitment and their intention to stay. In particular, they found that nurses who felt they had good relationships in their workplace were more committed to the ward than those who felt they were only there to earn a living.

In their Canadian study, Hayward et al (2016) demonstrated how nurses’ decisions to leave were influenced by their work environment, poor relationships with physicians and poor leadership, which left them feeling ill-equipped to perform their job. Similar findings were observed in Italy by Galetta et al (2013), who found that the intention to leave was significantly lower where nurses felt they had good relationships with nurse leaders. It was even lower where nurses also felt they had good relationships with medical staff.

Positive work environments

There is some evidence that relationships alone are not sufficient, and attention must also be paid to Herzberg’s other intrinsic factors (self-actualisation and personal growth). Nurse leaders must create positive work environments. As proposed by Laschinger et al (2014), positive work environments are achieved through a shared, collective perception (as opposed to a personal perception) of autonomy and structural empowerment.

This has been a cornerstone of the Magnet Recognition Program created by the American Nurses Credentialing Center. This is a development of the work conducted in the 1980s by the American Academy of Nursing – according to which, hospitals that were able to recruit and retain highly qualified nurses in a competitive market displayed 14 ‘forces of magnetism’, including quality of nursing leadership and management style (Royal College of Nursing, 2015). The subsequent accreditation scheme requires hospitals to have an explicit professional practice model.

The professional practice model defines each nurse’s individual autonomy to practise and therefore their empowerment – one of Laschinger’s requirements for a positive practice environment. Hoffart and Woods (1996) have described the five key elements of a professional practice model that an effective nurse leader must ensure are in place (Box 1). Lyons et al (2008) suggest that nurse leaders should develop their own local nursing strategy based on Hoffart and Woods’ principles.

Box 1. Five key elements of a professional practice model

Professional values
Professional relationships
Patient care delivery system
Management approach
Compensation and rewards structure

Source: Hoffart and Woods (1996)

While Hoffart and Woods’ model is an American model, Papastavavrou et al (2012) have compared survey results of nurses from six European countries and the US using the Revised Professional Practice Environment scale (Erickson et al, 2009). They did find some differences between nurses in Northern Europe, Mediterranean countries and the USA regarding perceptions of control over practice, but none regarding intrinsic work motivation.

Futher evidence of the universal application of the concept comes from Joyce and Crookes (2007) who adapted the Nursing Work Index-Revised (NWI-R) for the Australian setting to audit ‘magnetism’ in Australian hospitals, obtaining acceptable internal consistency scores. Interest in measuring the practice environment in Australia was also shown by Flint et al (2010), who validated the Brisbane Practice Environment Measure.

The elements of the different professional practice models are not explicitly linked to a single style of leadership and may be used with a number of approaches – and indeed with a mix of the different leadership theories.

So what can we conclude about nurse leadership? There is some evidence that good leadership can have a positive impact on patient outcomes through creating the conditions, which allow nurses to reach their full potential and build both personal and organisational resilience in the face of unexpected or increased workload. The evidence suggests that nurse leaders should adapt their leadership behaviours:

To the task at hand – which may require a transactional approach;
To the needs of the team – which may require a transformational approach;
To the pivotal requirement of building and maintaining productive relationships.

Given the uncertainties that nurse leaders face in their daily work, they can only achieve this by being constantly aware of the changing environment and making sense of it. Box 2 lists four key skills of nurse leaders. Nurse leadership is in truth a pragmatic blend of theory and evidence, adapted to the local circumstances, flexible enough to respond to the reactions of the team, and agile enough to deal with the unexpected.

Box 2. Four key skills of nurse leaders

Monitoring and calibrating the team’s workload
Creating a work environment in which all staff feel they can contribute the maximum in a fulfilling way for them
Creating relationships that build resilience
Ensuring that the team deliver safe care, good experience (for patients and for staff) and the best use of available resources

Talking points

Good nurse leadership can have a positive impact on both patient experience and outcomes, and nurse satisfaction and retention
Transactional leadership – traditionally considered undesirable – has been shown to improve patient satisfaction
It is the nature of the relationship between leaders and followers, rather than any specific behaviours of leaders, that produces effective leadership
Nurse leaders must create a collective perception of autonomy and empowerment to create positive work environments
There is no single best style in nurse leadership and a nuanced blend of approaches should be adopted

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As there is no effective approach in nursing leadership, creation of an atmosphere that promotes good relationship amongst the team is one of the essential part of a good leadership, be a role model to your team. Good nurse leadership manifested itself with good impact to both patient and staff.

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Effective Leadership and Management in Nursing Essay

To find inspiration for your paper and overcome writer’s block
As a source of information (ensure proper referencing)
As a template for you assignment

Academic Specialization

Marietta j. bell scriber’s mentorship, contribution.

In the field of nursing, mentors assist in critically advising and supporting students, they are our primary sources of valuable information on program operations, policies, and measures. In addition, they guide us on our career objectives and how to overcome obstacles and ensure success (Bell-Scriber & Morton 2009).

My mentor is Marietta J. Bell Scriber. Marietta holds a degree from Saginaw General Hospital School of Nursing. She holds a Bachelor of Science in Nursing (BSN) from Ferris State University, a Master’s of Science in Nursing from Grand Valley State University and a Ph.D. from Michigan State University.

Marietta specializes in the area of cardiovascular nursing. She also deals with nursing administration, family nursing, cultural diversity, and global consciousness.

Currently, she is an associate professor and she is still researching cultural diversity in relation to the nursing profession and practices. She holds a leadership position as the chairperson of Epsilon Eta chapter; this society assists in the advancement of nursing students through scholarships. I contacted her through the internet social media, read her various publications as well as attended her inspiring presentations.

Marietta’s personal interest in mentoring and genuine concern in student performance has contributed to her success as a mentor. This is evident in most of her inspirational books and various presentations. She also provides education to others as she will soon be teaching in the Republic of Cyprus as Fulbright scholar. She also offers guidance on time management, schedule benchmarks, and program concepts, which have assisted me in developing unique nursing skills and knowledge. In addition, she has helped me identify my strengths and weaknesses and overcome my weaknesses.

In her publications, she highlights the importance and ways of achieving quality and unique health care policies and good work ethics. These are essential for every nursing student worldwide. She emphasizes on the importance of consistency and proper protocol in nursing (American Psychological Association, 2010).

She also puts a lot of emphasis on interprofessional team building in nursing as a career as well as sharing of information. It does not only increase awareness but also reinforces student’s knowledge and helps in demonstrating one’s skills. By being a leader at Chair of Epsilon Eta Chapter, she has been able to assist many nursing students and contributed to a positive move in the nursing profession. She also helps nursing students in becoming effective leaders in future and in proper management in nursing. This includes stress management at work place since nursing is a very sensitive career (Sullivan, 2012).

The other common factors that she puts emphasis on are nurse coaching and discipline to assist future nurses maintain proper ethics and learn policies at work places about how to deal with problems as they arise and to improve problem solving skills. This includes the importance of professional behavior and proper communication. In her effort to support the nursing students, she highlights and discusses the importance of effective and efficient leadership in nursing and various ways of motivating and improving staff including career advancements. The importance of proper planning and reducing time wastage such as proper bookings are also essential and critical in nursing as they assist a nurse in setting and achieving departmental, professional, financial and social goals (Amer, 2013).

Amer, K. (2013). Quality and safety for transformational nursing: Core Competencies . Upper Saddle River, New Jersey: Pearson.

American Psychological Association. (2010). Publication manual of the American Psychological Association . Washington, DC.

Bell-Scriber, M. & Morton, A. (2009). Clinical Instruction Institute: Train the trainer. Nurse Educator, Michigan, USA: Ferris State University.

Sullivan, J. (2012). Effective leadership and management in nursing (8th ed.). Upper Saddle River, New Jersey: Pearson.

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Leadership Effectiveness in Healthcare Settings: A Systematic Review and Meta-Analysis of Cross-Sectional and Before–After Studies

Vincenzo restivo.

1 Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE) “G. D’Alessandro”, University of Palermo, Via del Vespro 133, 90127 Palermo, Italy

Giuseppa Minutolo

Alberto battaglini.

2 Vaccines and Clinical Trials Unit, Department of Health Sciences, University of Genova, Via Antonio Pastore 1, 16132 Genova, Italy

Alberto Carli

3 Santa Chiara Hospital, Largo Medaglie d’oro 9, 38122 Trento, Italy

Michele Capraro

4 School of Public Health, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy

Maddalena Gaeta

5 Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Via Forlanini 2, 27100 Pavia, Italy

Cecilia Trucchi

6 Planning, Epidemiology and Prevention Unit, Liguria Health Authority (A.Li.Sa.), IRCCS San Martino Hospital, Largo R. Benzi 10, 16132 Genoa, Italy

Carlo Favaretti

7 Centre on Leadership in Medicine, Catholic University of the Sacred Heart, Largo F. Vito 1, 00168 Rome, Italy

Francesco Vitale

Alessandra casuccio, associated data.

Data will be available after writing correspondence to the author.

To work efficiently in healthcare organizations and optimize resources, team members should agree with their leader’s decisions critically. However, nowadays, little evidence is available in the literature. This systematic review and meta-analysis has assessed the effectiveness of leadership interventions in improving healthcare outcomes such as performance and guidelines adherence. Overall, the search strategies retrieved 3,155 records, and 21 of them were included in the meta-analysis. Two databases were used for manuscript research: PubMed and Scopus. On 16th December 2019 the researchers searched for articles published in the English language from 2015 to 2019. Considering the study designs, the pooled leadership effectiveness was 14.0% (95%CI 10.0–18.0%) in before–after studies, whereas the correlation coefficient between leadership interventions and healthcare outcomes was 0.22 (95%CI 0.15–0.28) in the cross-sectional studies. The multi-regression analysis in the cross-sectional studies showed a higher leadership effectiveness in South America (β = 0.56; 95%CI 0.13, 0.99), in private hospitals (β = 0.60; 95%CI 0.14, 1.06), and in medical specialty (β = 0.28; 95%CI 0.02, 0.54). These results encourage the improvement of leadership culture to increase performance and guideline adherence in healthcare settings. To reach this purpose, it would be useful to introduce a leadership curriculum following undergraduate medical courses.

1. Introduction

Over the last years, patients’ outcomes, population wellness and organizational standards have become the main purposes of any healthcare structure [ 1 ]. These standards can be achieved following evidence-based practice (EBP) for diseases prevention and care [ 2 , 3 ] and optimizing available economical and human resources [ 3 , 4 ], especially in low-industrialized geographical areas [ 5 ]. This objective could be reached with effective healthcare leadership [ 3 , 4 ], which could be considered a network whose team members followed leadership critically and motivated a leader’s decisions based on the organization’s requests and targets [ 6 ]. Healthcare workers raised their compliance towards daily activities in an effective leadership context, where the leader succeeded in improving membership and performance awareness among team members [ 7 ]. Furthermore, patients could improve their health conditions in a high-level leadership framework. [ 8 ] Despite the leadership benefits for healthcare systems’ performance and patients’ outcomes [ 1 , 7 ], professionals’ confidence would decline in a damaging leadership context for workers’ health conditions and performance [ 4 , 9 , 10 ]. On the other hand, the prevention of any detrimental factor which might worsen both team performance and healthcare systems’ outcomes could demand effective leadership [ 4 , 7 , 10 ]. However, shifting from the old and assumptive leadership into a more effective and dynamic one is still a challenge [ 4 ]. Nowadays, the available evidence on the impact and effectiveness of leadership interventions is sparse and not systematically reported in the literature [ 11 , 12 ].

Recently, the spreading of the Informal Opinion Leadership style into hospital environments is changing the traditional concept of leadership. This leadership style provides a leader without any official assignment, known as an “opinion leader”, whose educational and behavioral background is suitable for the working context. Its target is to apply the best practices in healthcare creating a more familiar and collaborative team [ 2 ]. However, Flodgren et al. reported that informal leadership interventions increased healthcare outcomes [ 2 ].

Nowadays, various leadership styles are recognized with different classifications but none of them are considered the gold standard for healthcare systems because of heterogenous leadership meanings in the literature [ 4 , 5 , 6 , 12 , 13 ]. Leadership style classification by Goleman considered leaders’ behavior [ 5 , 13 ], while Chen DS-S proposed a traditional leadership style classification (charismatic, servant, transactional and transformational) [ 6 ].

Even if leadership style improvement depends on the characteristics and mission of a workplace [ 6 , 13 , 14 ], a leader should have both a high education in healthcare leadership and the behavioral qualities necessary for establishing strong human relationships and achieving a healthcare system’s goals [ 7 , 15 ]. Theoretically, any practitioner could adapt their emotive capacities and educational/working experiences to healthcare contexts, political lines, economical and human resources [ 7 ]. Nowadays, no organization adopts a policy for leader selection in a specific healthcare setting [ 15 ]. Despite the availability of a self-assessment leadership skills questionnaire for aspirant leaders and a pattern for the selection of leaders by Dubinsky et al. [ 15 ], a standardized and universally accepted method to choose leaders for healthcare organizations is still argued over [ 5 , 15 ].

Leadership failure might be caused by the arduous application of leadership skills and adaptive characteristics among team members [ 5 , 6 ]. One of the reasons for this negative event could be the lack of a standardized leadership program for medical students [ 16 , 17 ]. Consequently, working experience in healthcare settings is the only way to apply a leadership style for many medical professionals [ 12 , 16 , 17 ].

Furthermore, the literature data on leadership effectiveness in healthcare organizations were slightly significant or discordant in results. Nevertheless, the knowledge of pooled leadership effectiveness should motivate healthcare workers to apply leadership strategies in healthcare systems [ 12 ]. This systematic review and meta-analysis assesses the pooled effectiveness of leadership interventions in improving healthcare workers’ and patients’ outcomes.

2. Materials and Methods

A systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement guidelines [ 18 ]. The protocol was registered on the PROSPERO database with code CRD42020198679 on 15 August 2020. Following these methodological standards, leadership interventions were evaluated as the pooled effectiveness and influential characteristic of healthcare settings, such as leadership style, workplace, settings and the study period.

2.1. Data Sources and Search Strategy

PubMed and Scopus were the two databases used for the research into the literature. On 16th December 2019, manuscripts in the English language published between 2015 and 2019 were searched by specific MeSH terms for each dataset. Those for PubMed were “leadership” OR “leadership” AND “clinical” AND “outcome” AND “public health” OR “public” AND “health” OR “public health” AND “humans”. Those for Scopus were “leadership” AND “clinical” AND “outcome” AND “public” AND “health”.

2.2. Study Selection and Data Extraction

In accordance with the PRISMA Statement, the following PICOS method was used for including articles [ 18 ]: the target population was all healthcare workers in any hospital or clinical setting (Population); the interventions were any leader’s recommendation to fulfil quality standards or performance indexes of a healthcare system (Intervention) [ 19 ]; to be included, the study should have a control group or reference at baseline as comparison (Control); and any effectiveness measure in terms of change in adherence to healthcare guidelines or performances (Outcome). In detail, any outcome implicated into healthcare workers’ capacity and characteristics in reaching a healthcare systems purposes following the highest standards was considered as performance [ 19 ]. Moreover, whatever clinical practices resulted after having respected the recommendations, procedures or statements settled previously was considered as guideline adherence [ 20 ]. The selected study design was an observational or experimental/quasi-experimental study design (trial, case control, cohort, cross-sectional, before-after study), excluding any systematic reviews, metanalyses, study protocol and guidelines (Studies).

The leaders’ interventions followed Chen’s leadership styles classification [ 6 ]. According to this, the charismatic leadership style can be defined also as an emotive leadership because of members’ strong feelings which guide the relationship with their leader. Its purpose is the improvement of workers’ motivation to reach predetermined organizational targets following a leader’s planning strategies and foresights. Servant leadership style is a sharing leadership style in whose members can increase their skills and competences through steady leader support, and they have a role in an organization’s goals. The transformational leadership style focuses on practical aspects such as new approaches for problem solving, new interventions to reach purposes, future planning and viewpoints sharing. Originality in a transformational leadership style has a key role of improving previous workers’ and healthcare system conditions in the achievement of objectives. The transactional leadership style requires a working context where technical skills are fundamental, and whose leader realizes a double-sense sharing process of knowledge and tasks with members. Furthermore, workers’ performances are improved through a rewarding system [ 6 ].

In this study, the supervisor trained the research team for practical manuscript selection and data extraction. The aim was to ensure data homogeneity and to check the authors’ procedures for selection and data collection. The screening phase was performed by four researchers reading each manuscript’s title and abstract independently and choosing to exclude any article that did not fulfill the inclusion criteria. Afterwards, the included manuscripts were searched for in the full text. They were retrieved freely, by institutional access or requesting them from the authors.

The assessment phase consisted of full-text reading to select articles following the inclusion criteria. The supervisor solved any contrasting view about article selection and variable selection.

The final database was built up by collecting the information from all included full-text articles: author, title, study year, year of publication, country/geographic location, study design, viability and type of evaluation scales for leadership competence, study period, type of intervention to improve leadership awareness, setting of leader intervention, selection modality of leaders, leadership style adopted, outcomes assessed such as guideline adherence or healthcare workers’ performance, benefits for patients’ health or patients’ outcomes improvement, public or private hospitals or healthcare units, ward specialty, intervention in single specialty or multi-professional settings, number of beds, number of healthcare workers involved in leadership interventions and sample size.

Each included article in this systematic review and meta-analysis received a standardized quality score for the specific study design, according to Newcastle–Ottawa, for the assessment of the quality of the cross-sectional study, and the Study Quality Assessment Tools by the National Heart, Lung, and Blood Institute were used for all other study designs [ 21 , 22 ].

2.3. Statistical Data Analysis

The manuscripts metadata were extracted in a Microsoft Excel spreadsheet to remove duplicate articles and collect data. The included article variables for the quantitative meta-analysis were: first author, publication year, continent of study, outcome, public or private organization, hospital or local healthcare unit, surgical or non-surgical ward, multi- or single-professionals, ward specialty, sample size, quality score of each manuscript, leadership style, year of study and study design.

The measurement of the outcomes of interest (either performance or guidelines adherence) depended on the study design of the included manuscripts in the meta-analysis:

for cross-sectional studies, the outcome of interest was the correlation between leadership improvement and guideline adherence or healthcare performance;
the outcome derived from before–after studies or the trial was the percentage of leadership improvement intervention in guideline adherence or healthcare performance;
the incidence occurrence of improved results among exposed and not exposed healthcare workers of leadership interventions and the relative risks (RR) were the outcomes in cohort studies;
the odds ratio (OR) between the case of healthcare workers who had received a leadership intervention and the control group for case-control studies.

Pooled estimates were calculated using both the fixed effects and DerSimonian and Laird random effects models, weighting individual study results by the inverse of their variances [ 23 ]. Forest plots assessed the pooled estimates and the corresponding 95%CI across the studies. The heterogeneity test was performed by a chi-square test at a significance level of p < 0.05, reporting the I 2 statistic together with a 25%, 50% or 75% cut-off, indicating low, moderate, and high heterogeneity, respectively [ 24 , 25 ].

Subgroup analysis and meta-regression analyses explored the sources of significant heterogeneity. Subgroup analysis considered the leadership style (charismatic, servant, transactional and transformational), continent of study (North America, Europe, Oceania), median cut-off year of study conduction (studies conducted between 2005 and 2011 and studies conducted between 2012 and 2019), type of hospital organization (public or private hospital), type of specialty (surgical or medical specialty) and type of team (multi-professional or single-professional team).

Meta-regression analysis considered the following variables: year of starting study, continent of study conduction, public or private hospital, surgical or non-surgical specialty ward, type of healthcare service (hospital or local health unit), type of healthcare workers involved (multi- or single-professional), leadership style, and study quality score. All variables included in the model were relevant in the coefficient analysis.

To assess a potential publication bias, a graphical funnel plot reported the logarithm effect estimate and related the standard error from each study, and the Egger test was performed [ 26 , 27 ].

All data were analyzed using the statistical package STATA/SE 16.1 (StataCorp LP, College 482 Station, TX, USA), with the “metan” command used for meta-analysis, and “metafunnel”, “metabias” and “confunnel” for publication bias assessment [ 28 ].

3.1. Studies Characteristics

Overall, the search strategies retrieved 3,155 relevant records. After removing 570 (18.1%) duplicates, 2,585 (81.9%) articles were suitable for the screening phase, of which only 284 (11.0%) articles were selected for the assessment phase. During the assessment phase, 263 (92.6%) articles were excluded. The most frequent reasons of exclusion were the absence of relevant outcomes ( n = 134, 51.0%) and other study designs ( n = 61, 23.2%). Very few articles were rejected due to them being written in another language ( n = 1, 0.4%), due to the publication year being out of 2015–2019 ( n = 1, 0.4%) or having an unavailable full text ( n = 3, 1.1%).

A total of 21 (7.4%) articles were included in the qualitative and quantitative analysis, of which nine (42.9%) were cross-sectional studies and twelve (57.1%) were before and after studies ( Figure 1 ).

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Flow-chart of selection manuscript phases for systematic review and meta-analysis on leadership effectiveness in healthcare workers.

The number of healthcare workers enrolled was 25,099 (median = 308, IQR = 89–1190), including at least 2,275 nurses (9.1%, median = 324, IQR = 199–458). Most of the studies involved a public hospital ( n = 16, 76.2%). Among the studies from private healthcare settings, three (60.0%) were conducted in North America. Articles which analyzed servant and charismatic leadership styles were nine (42.9%) and eight (38.1%), respectively. Interventions with a transactional leadership style were examined in six (28.6%) studies, while those with a transformational leadership style were examined in five studies (23.8%). Overall, 82 healthcare outcomes were assessed and 71 (86.6%) of them were classified as performance. Adherence-to-guidelines outcomes were 11 (13.4%), which were related mainly to hospital stay ( n = 7, 64.0%) and drug administration ( n = 3, 27.0%). Clements et al. and Lornudd et al. showed the highest number of outcomes, which were 19 (23.2%) and 12 (14.6%), respectively [ 29 , 30 ].

3.2. Leadership Effectiveness in before–after Studies

Before–after studies ( Supplementary Table S1 ) involved 22,241 (88.6%, median = 735, IQR = 68–1273) healthcare workers for a total of twelve articles, of which six (50.0%) consisted of performance and five (41.7%) of guidelines adherence and one (8.3%) of both outcomes. Among healthcare workers, there were 1,294 nurses (5.8%, median = 647, IQR = 40–1,254). Only the article by Savage et al. reported no number of involved healthcare workers [ 31 ].

The number of studies conducted after 2011 or between 2012–2019 was seven (58.3%), while only one (8.3%) article reported a study beginning both before and after 2011. Most of studies were conducted in Northern America ( n = 5, 41.7%). The servant leadership style and charismatic leadership style were the most frequently implemented, as reported in five (41.7%) and four (33.3%) articles, respectively. Only one (8.3%) study adopted a transformational leadership style.

The pooled effectiveness of leadership was 14.0% (95%CI 10.0–18.0%), with a high level of heterogeneity (I 2 = 99.9%, p < 0.0001) among the before–after studies ( Figure 2 ).

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Effectiveness of leadership in before after studies. Dashed line represents the pooled effectiveness value [ 29 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ].

The highest level of effectiveness was reported by Weech-Maldonado R et al. with an effectiveness of 199% (95%CI 183–215%) based on the Cultural Competency Assessment Tool for Hospitals (CCATH) [ 39 ]. The effectiveness of leadership changed in accordance with the leadership style ( Supplementary Figure S1 ) and publication bias ( Supplementary Figure S2 ).

Multi-regression analysis indicated a negative association between leadership effectiveness and studies from Oceania, but this result was not statistically significant (β = −0.33; 95% IC −1.25, 0.59). On the other hand, a charismatic leadership style affected healthcare outcomes positively even if it was not statistically relevant (β = 0.24; 95% IC −0.69, 1.17) ( Table 1 ).

Correlation coefficients and multi-regression analysis of leadership effectiveness in before–after studies.

Variables	Correlation Coefficient	Beta Coefficient	95% CI
Studies conducted between 2012–2019 vs. 2005–2011 years	−0.26	−0.09	−0.42	0.24
North American continent vs. others	0.27	−0.04	−0.82	0.75
Oceanian continent vs. others	−0.26	−0.33	−1.25	0.59
European continent vs. others	0.07	−0.27	−1.12	0.58
Public hospital vs. private hospital	0.01
Surgical specialty vs. non-surgical specialty	−0.21	−0.05	−0.85	0.75
Leadership style transformational vs. other styles	0.12	0.32	−0.47	1.11
Leadership style charismatic vs. other styles	−0.23	0.24	−0.69	1.17
Leadership style transactional vs. other styles	0.25	0.25	−0.40	0.91

3.3. Leadership Effectiveness in Cross Sectional Studies

A total of 2858 (median = 199, IQR = 110–322) healthcare workers were involved in the cross-sectional studies ( Supplementary Table S2 ), of which 981 (34.3%) were nurses. Most of the studies were conducted in Asia ( n = 4, 44.4%) and North America ( n = 3, 33.3%). All of the cross-sectional studies regarded only the healthcare professionals’ performance. Multi-professional teams were involved in seven (77.8%) studies, and they were more frequently conducted in both medical and surgical wards ( n = 6, 66.7%). The leadership styles were equally distributed in the articles and two (22.2%) of them examined more than two leadership styles at the same time.

The pooled effectiveness of the leadership interventions in the cross-sectional studies had a correlation coefficient of 0.22 (95%CI 0.15–0.28), whose heterogeneity was remarkably high (I 2 = 96.7%, p < 0.0001) ( Figure 3 ).

An external file that holds a picture, illustration, etc.
Object name is ijerph-19-10995-g003.jpg

Effectiveness of leadership in cross-sectional studies. Dashed line represents the pooled effectiveness value [ 30 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ].

The effectiveness of leadership in the cross-sectional studies changed in accordance with the leadership style ( Supplementary Figure S3 ) and publication bias ( Supplementary Figure S4 ).

Multi-regression analysis showed a higher leadership effectiveness in studies conducted in South America (β = 0.56 95%CI 0.13–0.99) in private hospitals (β = 0.60; 95%CI 0.14–1.06) and in the medical vs. surgical specialty (β = −0.22; 95%CI −0.54, −0.02) ( Table 2 ).

Multi-regression analysis of leadership effectiveness in cross-sectional studies.

Variables	Correlation Coefficient	Beta Coefficient	95% CI
Studies conducted between 2012–2019 vs. 2005–2011 years	−0.31	−0.09	−0.27	0.10
South American continent vs. others	0.63	0.56 *	0.13	0.99
Private hospital vs. public hospital	0.17	0.60 *	0.14	1.06
Surgical specialty vs. non-surgical specialty	−0.22	−0.28 *	−0.54	−0.02
Leadership style transformational vs. other styles	0.41	0.16	−0.14	0.46
Leadership style charismatic vs. other styles	−0.14	−0.04	−0.26	0.18
Leadership style transactional vs. other styles	−0.11	0.01	−0.21	0.23
Multiprofessional team vs. single professional team	0.04

* 0.05 ≤ p < 0.01.

4. Discussion

Leadership effectiveness in healthcare settings is a topic that is already treated in a quantitative matter, but only this systematic review and meta-analysis showed the pooled effectiveness of leadership intervention improving some healthcare outcomes such as performance and adherence to guidelines. However, the assessment of leadership effectiveness could be complicated because it depends on the study methodology and selected outcomes [ 12 ]. Health outcomes might benefit from leadership interventions, as Flodgren et al. was concerned about opinion leadership [ 2 ], whose adhesion to guidelines increased by 10.8% (95% CI: 3.5–14.6%). On the other hand, other outcomes did not improve after opinion leadership interventions [ 2 ]. Another review by Ford et al. about emergency wards reported a summary from the literature data which acknowledged an improvement in trauma care management through healthcare workers’ performance and adhesion to guidelines after effective leadership interventions [ 14 ]. Nevertheless, some variables such as collaboration among different healthcare professionals and patients’ healthcare needs might affect leadership intervention effectiveness [ 14 ]. Therefore, a defined leadership style might fail in a healthcare setting rather than in other settings [ 5 , 13 , 14 ].

The leadership effectiveness assessed through cross-sectional studies was higher in South America than in other continents. A possible explanation of this result could be the more frequent use of a transactional leadership style in this area, where the transactional leadership interventions were effective at optimizing economic resources and improving healthcare workers’ performance through cash rewards [ 48 ]. Financing methods for healthcare organizations might be different from one country to another, so the effectiveness of a leadership style can change. Reaching both economic targets and patients’ wellness could be considered a challenge for any leadership intervention [ 48 ], especially in poorer countries [ 5 ].

This meta-analysis showed a negative association between leadership effectiveness and studies by surgical wards. Other research has supported these results, which reported surgical ward performance worsened in any leadership context (charismatic, servant, transactional, transformational) [ 47 ]. In those workplaces, adopting a leadership style to improve surgical performance might be challenging because of nervous tension and little available time during surgical procedures [ 47 ]. On the other hand, a cross-sectional study declared that a surgical team’s performance in private surgical settings benefitted from charismatic leadership-style interventions [ 42 ]. This style of leadership intervention might be successful among a few healthcare workers [ 42 ], where creating relationships is easier [ 6 ]. Even a nursing team’s performance in trauma care increased after charismatic leadership-style interventions because of better communicative and supportive abilities than certain other professional categories [ 29 , 47 ]. However, nowadays there is no standardized leadership in healthcare basic courses [ 5 , 6 , 12 ]. Consequently, promoting leadership culture after undergraduate medical courses could achieve a proper increase in both leadership agreement and working wellness as well as a higher quality of care. [ 17 ]. Furthermore, for healthcare workers who have already worked in a healthcare setting, leadership improvement could consist of implementing basic knowledge on that topic. Consequently, they could reach a higher quality of care practice through working wellness [ 17 ] and overcoming the lack of previous leadership training [ 17 ].

Although very few studies have included in a meta-analysis examined in private healthcare settings [ 35 , 38 , 40 , 41 , 42 ], leadership interventions had more effectiveness in private hospitals than in public hospitals. This result could be related to the continent of origin, and indeed 60.0% of these studies were derived from North America [ 38 , 41 , 42 ], where patients’ outcomes and healthcare workers’ performance could influence available hospital budgets [ 38 , 40 , 41 , 42 ], especially in peripheral healthcare units [ 38 , 41 ]. Private hospitals paid more attention to the cost-effectiveness of any healthcare action and a positive balance of capital for healthcare settings might depend on the effectiveness of leadership interventions [ 40 , 41 , 42 ]. Furthermore, private healthcare assistance focused on nursing performance because of its impact on both a patients’ and an organizations’ outcomes. Therefore, healthcare systems’ quality could improve with effective leadership actions for a nursing team [ 40 ].

Other factors reported in the literature could affect leadership effectiveness, although they were not examined in this meta-analysis. For instance, professionals’ specialty and gender could have an effect on these results and shape leadership style choice and effectiveness [ 1 ]. Moreover, racial differences among members might influence healthcare system performance. Weech-Maldonado et al. found a higher compliance and self-improvement by black-race professionals than white ones after transactional leadership interventions [ 39 ].

Healthcare workers’ and patients’ outcomes depended on style of leadership interventions [ 1 ]. According to the results of this meta-analysis, interventions conducted by a transactional leadership style increased healthcare outcomes, though nevertheless their effectiveness was higher in the cross-sectional studies than in the before–after studies. Conversely, the improvement by a transformational leadership style was higher in before–after studies than in the cross-sectional studies. Both a charismatic and servant leadership style increased effectiveness more in the cross-sectional studies than in the before–after studies. This data shows that any setting required a specific leadership style for improving performance and guideline adherence by each team member who could understand the importance of their role and their tasks [ 1 ]. Some outcomes had a better improvement than others. Focusing on Savage et al.’s outcomes, a transformational leadership style improved checklist adherence [ 31 ]. The time of patients’ transport by Murphy et al. was reduced after conducting interventions based on a charismatic leadership style [ 37 ]. Jodar et al. showed that performances were elevated in units whose healthcare workers were subjected to transactional and transformational leadership-style interventions [ 1 ].

These meta-analysis results were slightly relevant because of the high heterogeneity among the studies, as confirmed by both funnel plots. This publication bias might be caused by unpublished articles due to either lacking data on leadership effectiveness, failing appropriate leadership strategies in the wrong settings or non-cooperating teams [ 12 ]. The association between leadership interventions and healthcare outcomes was slightly explored or gave no statistically significant results [ 12 ], although professionals’ performance and patients’ outcomes were closely related to the adopted leadership style, as reported by the latest literature sources [ 7 ]. Other aspects than effectiveness should be investigated for leadership. For example, the evaluation of the psychological effect of leadership should be explored using other databases.

The study design choice could affect the results about leadership effectiveness, making their detection and their statistical relevance tough [ 12 ]. Despite the strongest evidence of this study design [ 50 ], nowadays, trials about leadership effectiveness on healthcare outcomes are lacking and have to be improved [ 12 ]. Notwithstanding, this analysis gave the first results of leadership effectiveness from the available study designs.

Performance and adherence to guidelines were the main two outcomes examined in this meta-analysis because of their highest impact on patients, healthcare workers and hospital organizations. They included several other types of outcomes which were independent each other and gave different effectiveness results [ 12 ]. The lack of neither an official classification nor standardized guidelines explained the heterogeneity of these outcomes. To reach consistent results, they were classified into performance and guideline adherence by the description of each outcome in the related manuscripts [ 5 , 6 , 12 ].

Another important aspect is outcome assessment after leadership interventions, which might be fulfilled by several standardized indexes and other evaluation methods [ 40 , 41 ]. Therefore, leadership interventions should be investigated in further studies [ 5 ], converging on a univocal and official leadership definition and classification to obtain comparable results among countries [ 5 , 6 , 12 ].

5. Conclusions

This meta-analysis gave the first pooled data estimating leadership effectiveness in healthcare settings. However, some of them, e.g., surgery, required a dedicated approach to select the most worthwhile leadership style for refining healthcare worker performances and guideline adhesion. This can be implemented using a standardized leadership program for surgical settings.

Only cross-sectional studies gave significant results in leadership effectiveness. For this reason, leadership effectiveness needs to be supported and strengthened by other study designs, especially those with the highest evidence levels, such as trials. Finally, further research should be carried out to define guidelines on leadership style choice and establish shared healthcare policies worldwide.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph191710995/s1 , Figure S1. Leadership effectiveness by leadership style in before after studies; Figure S2. Funnel plot of before after studies; Figure S3. Leadership effectiveness in cross sectional studies by four leadership style; Figure S4. Funnel plot of cross-sectional studies; Table S1. Before after studies included in this systematic review and meta-analysis; Table S2. Cross-sectional studies included in this systematic review and meta-analysis. All outcomes were performance.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, V.R., A.C. (Alessandra Casuccio), F.V. and C.F.; methodology, V.R., M.G., A.O. and C.T.; software, V.R.; validation, G.M., A.B., A.C. (Alberto Carli) and M.C.; formal analysis, V.R.; investigation, G.M., A.B., A.C. (Alberto Carli) and M.C.; resources, A.C. (Alessandra Casuccio); data curation, G.M. and V.R.; writing—original draft preparation, G.M.; writing—review and editing, A.C. (Alessandra Casuccio), F.V., C.F., M.G., A.O., C.T., A.B., A.C. (Alberto Carli) and M.C.; visualization, G.M.; supervision, V.R.; project administration, C.F.; funding acquisition, A.C. (Alessandra Casuccio), F.V. and C.F. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Ethical review and approval were waived for this study due to secondary data analysis for the systematic review and meta-anlysis.

Informed Consent Statement

Not applicable.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Home — Essay Samples — Business — Leadership — The Importance of Effective Nursing Leadership

The Importance of Effective Nursing Leadership

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Definition and importance of nursing leadership, qualities and skills of effective nursing leaders, roles and responsibilities of nursing leaders, impact of nursing leadership on patient care, challenges and strategies in nursing leadership.

Wong, C. A., Cummings, G. G., & Ducharme, L. (2013). The relationship between nursing leadership and patient outcomes: a systematic review. Journal of Nursing Management, 21(1), 30-40.

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Essay: Leadership in Adult Nursing (reflective)

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Introduction Leadership is a process which involves individual activity to state desire objective and vision in a situation, providing support and motivating other people to attend set goals (Swearingen, 2009). Danae et al. (2017) believe that leadership is broadly recognised as a key aspect of overall effective healthcare. Therefore, nurses require strong leadership skills to accomplish various tasks to improve care quality. In this assignment, I will cross reference six experts (see appendices) from my professional development portfolio related to the four domains of standards of competence for preregistration nursing (NMC, 2010). Additionally, I will address each domain using Rolfe, Freshwater and Jasper (2001) reflection model, which is composed of three stages ‘what’, ‘so what’, and ‘now what’. This model is suitable to link practical experiences with theory, it helps to improve clinical practice and identify further learning opportunities; which will be addressed by formulating a S.M.A.R.T action plan (Doran, 1981). Domaine 1: Professional values What? Appendix 1 shows aspects of the professional values that I need to address. It contains mentor’s comment about patient advocacy skill. During my Nursing Practice 5 (NP5), I looked after a 56-year-old disabled woman with Spina Bifida who was alert and orientated, unable to move on her own, but, had clearly expressed her need to be moved every two hours to avoid another pressure ulcer as she had one before. This was not respected by health care assistant taking for excuses “the ward is very busy, she is not the only patient”. I regret I didn’t advocate for her. Furthermore, appendix 2, which is the leadership framework self-assessment tool demonstrates aspects of personal quality that I need to review. These are related to the (NMC, 2010) instructing nurses to take all reasonable steps to protect people who are vulnerable or at risk from harm, neglect or abuse. So what? Professionalism means practice through the application of the Code (NMC, 2017). In the UK, nurses must act as advocates for their patients, challenge poor practice and discriminatory attitudes and behaviour relating to the care of vulnerable people, (NMC, 2015). This is supported by the Royal College of Nursing (RCN) stating that speaking on behalf of another is an integral part of the nurse’s role (RCN, 2008). Moreover, The International Council of Nurses emphasises the need for nurses to respect the rights, values, customs and beliefs of individuals and families, and to advocate for equity and social justice in resource allocation and in access to health (ICN, 2012). Such endeavours are central, as illness nearly always increase levels of patient vulnerability and dependence (Marquis and Huston 2012). Emphasizing the fact that nurses should influence the way care is given in a manner that is open and responds to individual needs (RCN, 2015). Unfortunately, there have been cases where nurses have failed to provide fundamental care to patients. The report into the failing at the Mid Staffordshire Hospital identified poor leadership coupled with clinical staff accepting standards of care that should not have been tolerated (Ellis and Bach, 2015). More recently, Care Quality Commission (CQC) has issued a Warning Notice requiring some trusts to improve safety, patient consent and overall leadership (CQC, 2017). This accentuates the role of leadership in prioritising patient safety and in listening to and learning from patients (storey and Holti, 2013). Stressing the need for nurse leaders to be self-aware and recognise how their own values and principles may affect their practice (NMC, 2010). Leaders encourage teamwork by appreciating individuals’ contributions and ideas; this creates needed behaviour, such as shared respect, compassionate care, attention to detail, between team members (NHS Leadership Academy, 2013), and create a motivating work environment (Adair, 2002). Therefore, the quality of leadership has a direct impact on the quality of service provided at all levels. The leader’s obligation is to create an environment in which good people can provide good care (Engard, 2017). Pointing out personal attributes of nurses that help to enable advocacy like ﬂexibility, empathy, self-motivation, professional commitment, sense of responsibility, and the ability to cope with stress (Choi, 2015). Reflecting on the above scenario, transformational and transactional leadership can both play a role in the negotiation of a win-win situation. Transformational leadership is defined as a leadership approach that causes changes in individuals and social systems. It is about having a vision of how things should or could be and being able to communicate this idea effectively to others (Ellis and Bach, 2015). Whereas transactional leadership is based on contingent rewards and can have a positive effect on followers’ satisfaction and performance (Tomlinson, 2012). Transformational leadership plays a more critical role in the present scenario. it can motivate and inspire healthcare assistant and have a more significant impact to change both their thinking and behaviour Jie-HuiXu (2017), thus, allowing them to reach their potential and deliver sustainable changes to care. Now what? Now I should strive on developing and sustaining my engagement in patient advocacy by the end of NP7. In my Ongoing Achievement Record document, I will work with my mentor to complete competency 1.2. called: Understand and apply current legislation to all service users, paying special attention to the protection of vulnerable people, including those with complex needs. I will actively seek mentor, patients, family and others health professionals’ feedback and reflect on when I have been involved in patient advocacy during placement and review this with my mentor at mid- and end-point review. Domain 2: Communication and Interpersonal Skill What? Communication and interpersonal skill are vital parts of collaborative working (NMC, 2010). I reflect on communication using Situation, Background, Assessment and Recommendation (SBAR) mentioned in appendix 3, which is a reflective writing during placement 5. In a surgical ward, during routine observation of a patient who had undergone a cystectomy, I noticed that the patient was spiking in temperature (38.5) although NEWS score was 1, I immediately informed my mentor who directed me to blip the doctor in charge of his care. While communicating with him I was unable to give a clear response to questions about the patient’s condition. Even though he reassessed my patient immediately, I regret I didn’t use SBAR tool, because it could have helped to communicate clearly and prevent any potential delays. Appendix 1 in the section ‘working with others’ further shows that I need to improve my interpersonal skills. These relate to part of the NMC (2010) stating: nurses must use a range of communication skills and technologies to support person-centred care and enhance quality and safety. So what? Bach and Grant (2010) state that good communication and interpersonal skills are essential characteristics of high-quality nursing practice. The NMC (2010) also said that all nurses must use the full range of communication methods, including verbal, nonverbal and written, to acquire, interpret and record their knowledge and understanding of people’s needs. Emphasizing the use of communication tools like SBAR. SBAR is a tangible approach to framing conversations, especially critical ones that require a nurse’s instant attention and action. It promotes the provision of safe, efficient, timely, and patient-centred communication (Chaboyer et al., 2010; Day, 2010). Moreover, SBAR can be used for multiple forms of communication. It can be a change-of-shift report (Pope et al., 2008; Thomas et al., 2009), or can be applied to written communication (Perry, 2014). In addition, SBAR helps nursing students and recent graduate nurses organize their thoughts prior to calling physicians, to save time, reduce frustration, and improve overall communication (Pope et al., 2008). Furthermore, the use of SBAR communication tool temporarily flattens the hierarchy perceived in most healthcare settings, resulting in more effective channels of communication between healthcare providers (De Meester, Verspuy, Monsieurs, & Van Bogaert, 2013). According to Hackman and Johnson (2013), leadership is first, and foremost, a communication-based activity. Depending on the circumstances, a leader should try to be more authoritarian, democratic or laissez-faire (Mitchell, 2012); or should focus the communication on the tasks or use a more interpersonal style (Hackman and Johnson 2013). Reflecting on the scenario related to this domain, an assertive, clear and focus communication using SBAR format would have provided a brief, organized, predictable flow of information improving critical thinking communication skills and patient safety (Olin, 2012). It can be argued that it is hard to serve as an effective leader without effective communication (Hackman and Johnson 2013). This is agreed by Perry et al (2014) stating that effective commutation is a central attribute of clinical leadership. Clinical leaders can influence their colleagues with effective communication skill such as good listening skill and extremely good at explaining things at the right level that can be understood by followers. However, it is important to note that each clinical leader has a preferred style of communication that would not necessary works every time. Hackman and Johnson (2013) recommend choosing a leadership communication style that will work best according to the situation and the level of knowledge of followers. Now what? During next placement (NP7), I will strive to change communicating SBAR in a more professional, concise, clear, in a timely manner when communicating with the multidisciplinary team to improve patient outcome. I will actively seek feedback from my mentor and other professionals at mid- and end-point reviews. I will also change my preferred communication style from passive aggressive to an assertive communication style. For that, I will use the communication style questionnaire at the beginning then altered my behaviour during the first part of the placement, then repeat the questionnaire at mid-point and ask for feedback to my mentor base on the comparison on two questionnaire results and base on her observation. And repeat this again by end-point. Domain 3: Nursing Practice and Decision Making What? Here I reflect on nursing practice and decision making, see appendix 4, which is an end-point mentor comment during NP3 showing that improvement is needed in this domain. This is underpinned by appendix 5: a reflection done at the beginning of NP6 when I looked after a patient with hypoxic brain damaged who had a seizure. On my entry into his room, I found the patient unconscious, I took the decision to clear his airway before pressing the emergency bell which could have jeopardised patient safety. This is related to the NMC (2010) stating that nurses must be able to recognise and interpret signs of normal and deteriorating mental and physical health and respond promptly to maintain or improve the health and comfort of the service user. My behaviour pointed out the need to enhance my skill and knowledge in this domain. So what? Judgement and decision-making are important facets of healthcare for nurses (Traynor et al., 2010). Judgement is defined as weighing up different alternatives; while decision-making involves choosing a specific course of action to follow between alternatives (Lamb and Sevdalis, 2011). Hence, (Undre et al., 2009) define efficacious judgement and decision-making as skills that go beyond clinical knowledge and technical competence, highlighting the fact that nursing judgement and decision-making contribute significantly to the safety and quality of patient care (Traynor et al., 2010). However, several studies have high-pointed that when given the same information, and undertaking the same decisions, nurses will make consistently different judgements and decisions (Thompson et al., 2008; Thompson and Yang, 2009). Differing judgement and decision indicate different types of reasoning, in situations where time is not constrained, newly qualified nurses will make structured judgments with a rational-analytical decision. For those situations where time is limited, information is perceptual, and the nurse has some perceived expertise, it is appropriate to use intuition as the basis for judgement (Hammond et al., 1987). Thompson et al (2008) suggest that the key to successful reasoning is to adapt reasoning to the demands of the task. However, such adaptive reasoning by nurses is sometimes absent. Thus, good decisions and judgements are not independent to the cognitive process but can be influenced by how information is prioritised and the nurse’s ability to identify and respond to vital aspects of the clinical situation (Pearson, 2013). Thompson et al (2013) state that recent studies have shown positive benefits associated with the introduction of Computerised Decision Support Systems (CDSS) to support nursing decisions. Hence, helping to promote patient’s safety and improve their outcome. Reflecting on the scenario related to this domain, future decisions making process, whether they are based on normative, prescriptive or descriptive theory must include clinical expertise, patient value and best available research evidence (Sackett, 1996). because evidence by itself, does not make the decision, but it can help support the patient care process. In the same order, Marquis and Huston (2015) suggest that to be effective as a leader, one needs certain skills for making decisions, such as self-awareness, fairness and transparency which are skills also needed in decision making. This is supported by Thompson and Dowding (2009 p5) affirming that “One of the distinguishing features that mark out exceptional nurses is their skills in judgement and decision making”. Decision making is considered important leadership skills and is recognised by Sofarelli and Brown (1998) as qualities associated with transformational leadership. Now what? I have realised that decision making, particularly in nursing, is vital as it influences patient safety and outcomes (Ellis and Bach, 2015). It has been mention earlier that experience is a factor that affects decision making. To gained experience in judgement and decision making, I will use every opportunity during NP7 to practice evidence base in nursing practice and decision making by always based my decision on useful information sources like clinical guidelines, protocol and policy and patient preference. After what I will actively seek feedback from my mentor and others healthcare professionals and of course to patients to check their satisfaction about their involvement in the decision-making process about their own care at mid- and end-point reviews. . Domain 4: Leadership, management and team-working What? My leadership, management and team working skill are measured in appendix 2 and appendix 6 which are both leadership self-assessment tools. The first one showing aspects of my leadership that needs to be improved and the second one showing my leadership style which is “guiding” needing improvement to become more empowering. These are further supported by appendix 4: mentor end NP3 comment. During the leadership module, I took part in several group activities, which enabled me to understand team role importance and that there is no leader without followers. This part relates to NMC (2010) stating that nurses must work independently as well as in teams; be able to take the lead in coordinating, delegating and supervising care safely, managing risk and remaining accountable for care given. So what? Tomlison (2012) states that self-assessment helps individuals to appreciate their qualities, strengths and weaknesses thereby, enabling better transformational leadership. Bass (1985) found that transformational leadership contributes to individual performance and motivation. Whereas transactional leadership (Burns, 1978) is short-lived, and task-based, with the leader intervening with negative feedback when things go wrong. Adair (2002) proposed a three-circle model of strategic leadership, with the circles being the needs of the task, the individual and the team. This is a democratic model of leadership matching the NMC code, where Individuals and groups are involved in decision-making processes concerning their work (Adair, 2002). Management skills are as important as leadership skills in addressing some failings like those identified in the Francis report (Kerridge, 2013). Kerridge suggests they are closely linked, effective management and leadership both require putting first thing first. The King’s Fund report (2011) concurs, defining leadership as the art of motivating people toward a shared vision and management as getting the job done, suggesting that the exercise of leadership across shifts could be extended to management practice; pointing out that every member of healthcare team has some management and reporting functions as part of their job (Baker et al., 2012). Lord Darzi (2008) said: ‘Leadership is not just about individuals, but teams’. A successful leader will see each person as an individual, recognising their unique set of needs, as not everyone will perform at the same level (Hackman and Johnson 2013). This rejoins the description of team role by Belbin (1996) as he described a team role as ‘a tendency to behave, contribute and interrelate with others in a particular way’. Suggesting that Belbin assessment would be an ideal way for a team to examine: the roles they play, how these fit in with the team and the contribution of roles to the team (Frankel, 2011). Therefore, it would be advisable that team members use the questionnaire to helps identify individuals’ preferred roles, their manageable roles and their least preferred roles within the nine teams’ roles as described by Belbin in-order-to improve the success of teamwork. Nurse leaders need also to be able to respond to an ever-changing healthcare environment (Frankel, 2011). The literature suggests that leadership, effective communication and team working are among the most important elements for planned change (Schifalacqua et al., 2009a). Kurt (1951) identified three steps of change: unfreezing, moving and refreezing. This work was modified by Rogers (2003) who described five phases of planned change: awareness, interest, evaluation, trial and adoption. Another change theorist, Ronald Lippitt (Lippitt et al., (1958), identified seven phrases. Mitchell (2013) advises that Lippitt’s work is likely to be more useful to nurses because it incorporates a detailed plan of how to generate change and is underpinned by the four elements of the nursing process: assessment, planning, implementation and evaluation. Now what? To improve my Leadership, management and teamwork skills, I will use the first week of my MP7 to observe my mentor and nurses in charge leading some shifts, then, I will seek clarification on grey areas of my understanding and ask to have my own patients. This will enable me to practice leading others, managing patients and working with the multidisciplinary team. I will actively seek feedback till mid-point review, then, I will lead and manage my mentor whole set of patients under her observation and correction whenever needs arise till end-point. This will help me to move toward an empowering leadership style. Conclusion I have learnt that: a good leader or manager remains grounded in the values, beliefs and behaviours that guide professional nursing practice; understanding your role and that of other will nurture clear communication thus improving the success of the team; safe decision-making must be evidence-based; and effective leadership fosters a high-quality work environment leading to positive safe climate that assures better patient outcomes.

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Reflection: Application of Leadership Skills in Nursing

Info: 5480 words (22 pages) Nursing Essay Published: 11th Feb 2020

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1. Introduction

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3. Leadership in Practice

4. leadership styles applied to the complexity of delivery of care., 5. leadership benefits to the quality of client care., 6. dynamic and flexible approaches to leadership issues., 7. conclusion, 8. recommendations, 9. appendix, 11. references, department of health, cphva, unite & nhs (2009b) getting it right for children and families. maximising the contribution of the health visiting team. ‘ambition, action, achievement’. london: the stationery office., cite this work.

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Impact of Nurse Leaders Behaviors on Nursing Staff Performance: A Systematic Review of Literature
Nursing leadership is critical in facilitating and improving nurse performance, which is essential for providing quality care and ensuring patient safety. ... In this context, it may be implied that effective leadership approaches coupled with systematic management of nursing resources could be one of the effective ways to improve nursing ...
The Impact of Transformational Leadership in the Nursing Work
Background: With the increasingly demanding healthcare environment, patient safety issues are only becoming more complex. This urges nursing leaders to adapt and master effective leadership; particularly, transformational leadership (TFL) is shown to scientifically be the most successfully recognized leadership style in healthcare, focusing on relationship building while putting followers in ...
Leadership in Nursing: Qualities & Why It Matters
This nursing leadership style works well with mentoring. The Autocratic nurse leader makes quick decisions with little input from employees and excels at task delegation. This nursing leadership style may be most effective in an emergency. A Laissez-faire leadership style puts faith in every facet of a well-oiled machine. This method may work ...
The essentials of nursing leadership: A systematic review of factors
The findings of this review make it clear that targeted educational interventions are an effective method of leadership development in nurses. However, due to equivocal results reported in many included studies and heterogeneity of leadership measurement tools, few conclusions can be drawn regarding …
Importance of Leadership Style towards Quality of Care Measures in
Effective leadership of healthcare professionals is critical for strengthening quality and integration of care. This study aimed to assess whether there exist an association between different leadership styles and healthcare quality measures. ... Papers published from 2004 to 2015 (focus on more recent knowledge) ... Hospital Nursing leadership ...
How leadership matters: Clinical nurses' perceptions of... : Nursing
The link to nursing leadership is obvious—ethics, positive change, purpose, growth, and social connection are all part of who we are as nurses and nurse leaders. The most common relational leadership styles are transformational, authentic, and servant. All three leadership styles have connections to healthy work environments and staff ...
Developing effective nurse leadership skills
This article examines the importance of effective leadership for nurses, patients and healthcare organisations, and outlines some of the theories of leadership such as transformational leadership. It also details how nurses can develop their leadership skills, for example through self-awareness, critical reflection and role modelling. Nursing ...
The essentials of nursing leadership: A systematic review of factors
Moreover, effective nursing leadership practices have critical implications for improved health care quality and patient outcomes (Wong et al., 2013; ... 93 studies (reported in 100 papers) of 554 manuscripts screened through full-text review, were included. The final 93 included 44 correlational studies and 49 pre/post intervention studies.
PDF Attributes, skills and actions of clinical leadership in nursing as
tiveness of care, effective nursing leadership is warranted.4 11-17 Clinical leaders can be found in various healthcare settings,4 most often at the highest clinical level, but they are uncommon at the top executive level. 6-9 18-24 In the UK, the National Health
Reflection On Leadership And Management Skills
The importance of leadership is now widely recognised as a key part of overall effective healthcare, and nursing leadership is a crucial part of this as nurses are now the single largest healthcare discipline. Research into nursing leadership has shown that a culture of good leadership within healthcare is linked to improved patient outcomes ...
Good leadership in nursing: what is the most effective approach?
Nurse leadership is in truth a pragmatic blend of theory and evidence, adapted to the local circumstances, flexible enough to respond to the reactions of the team, and agile enough to deal with the unexpected. Box 2. Four key skills of nurse leaders. Monitoring and calibrating the team's workload.
Leadership in Nursing
A clinical nursing leader is one who is involved in direct patient care and who continuously improves the care that is afforded to such persons by influencing the treatment provision delivered by others (Cook, 2001). Leadership is not merely a series of skills or tasks; rather, it is an attitude that informs behaviour (Cook, 2001).
Effective Leadership and Management in Nursing Essay
Effective Leadership and Management in Nursing Essay. In the field of nursing, mentors assist in critically advising and supporting students, they are our primary sources of valuable information on program operations, policies, and measures. In addition, they guide us on our career objectives and how to overcome obstacles and ensure success ...
Effective Leadership and Teamwork in Nursing
Good quality leadership skills are the solution to enabling teams to provide high quality effective patient care. Effective team leadership improves satisfaction among team members and patients and improves productivity. In order to be effective as a leader the team leader must be visible and approachable. Team working within a hospital setting ...
Leadership Effectiveness in Healthcare Settings: A Systematic Review
1. Introduction. Over the last years, patients' outcomes, population wellness and organizational standards have become the main purposes of any healthcare structure [].These standards can be achieved following evidence-based practice (EBP) for diseases prevention and care [2,3] and optimizing available economical and human resources [3,4], especially in low-industrialized geographical areas [].
Importance of Leadership in Nursing: Styles and Impact
Leadership in nursing is a critical component of healthcare delivery, influencing patient outcomes, nurse performance, job satisfaction, and the overall quality of care. This essay explores the significance of leadership in nursing by examining various leadership styles, including transformational, democratic, autocratic, and servant leadership, and their impact on patient outcomes and nursing ...
The Importance of Leadership in Nursing
The importance of leadership is now widely recognised as a key part of overall effective healthcare, and nursing leadership is a crucial part of this as nurses are now the single largest healthcare discipline (Swearingen, 2009). The findings of the Francis Report (2013) raised major questions into the leadership and organisational culture which allowed hundreds of patients to die or come to ...
The Importance of Effective Nursing Leadership
Nursing leadership is an essential component of healthcare delivery, with effective leadership playing a critical role in providing quality patient care and improving healthcare outcomes. This essay will explore the definition, importance, qualities, and skills of effective nursing leaders, as well as their roles, responsibilities, and impact on patient care.
Essay: Leadership in Adult Nursing (reflective)
Introduction. Leadership is a process which involves individual activity to state desire objective and vision in a situation, providing support and motivating other people to attend set goals (Swearingen, 2009). Danae et al. (2017) believe that leadership is broadly recognised as a key aspect of overall effective healthcare.
Effective Leadership and Management in Nursing Essay examples
Transformational leadership has proven to be an effective leadership style in the nursing profession, demonstrating a clear mission, a commitment to excellence, and the ability to motivate and lead others to higher levels of achievement (Schwartz, Spencer, Wilson, & Wood, 2001). Characteristics and qualities of an effective leader include.
Effective Leadership In Nursing Practice
Effective Leadership In Nursing Practice. Leadership is a trend of a crew and interactive it to people, encouraging, motivating and permitting them to underwrite to accomplishing organisational victory. The leadership requires being strategically focused and his performance practices to build obligation and achieve the best effort from your people.
Essay on Effective Leadership and Management in Nursing
Instructor: Linda Westermann. March 12, 2012. Effective Leadership and Management in Nursing According to Sullivan and Decker (2009), leadership is influencing others into working toward accomplishing a common goal. Some people are born with an innate leadership quality within them. Others require learning leadership and management skills.
Reflection: Application of Leadership Skills in Nursing
1. Introduction. 1.1 This report looks at my existing leadership skills and how they have developed when implementing a postnatal group within my practice. Through developing this group, I will look at how the team responds to my leadership and how I approach situations. As part of my continuing professional development, I will identify changes ...

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The essentials of nursing leadership: A systematic review of factors and educational interventions influencing nursing leadership

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How leadership matters

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INSTRUCTIONS How leadership matters: Clinical nurses' perceptions of leader behaviors affecting their work environment

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Good leadership in nursing: what is the most effective approach?

Introduction

Transactional or transformational?

New ways of thinking

You cannot enforce leadership

A plethora of models

Impact on patient outcomes

Impact on nurse satisfaction

Positive work environments

Talking points

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Effective Leadership and Management in Nursing Essay

Academic Specialization

Leadership Effectiveness in Healthcare Settings: A Systematic Review and Meta-Analysis of Cross-Sectional and Before–After Studies

Giuseppa Minutolo

Alberto Carli

Michele Capraro

Maddalena Gaeta

Cecilia Trucchi

Carlo Favaretti

Francesco Vitale

1. Introduction

2. Materials and Methods

2.1. Data Sources and Search Strategy

2.2. Study Selection and Data Extraction

2.3. Statistical Data Analysis

3.1. Studies Characteristics

3.2. Leadership Effectiveness in before–after Studies

3.3. Leadership Effectiveness in Cross Sectional Studies

4. Discussion

5. Conclusions

Supplementary Materials

Funding Statement

Author Contributions

Institutional Review Board Statement

Informed Consent Statement

Data Availability Statement

The Importance of Effective Nursing Leadership

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Essay: Leadership in Adult Nursing (reflective)