Cummings, et al. (2010) found that relational leadership led to greater productivity, effectiveness, and extra effort when compared to task-focused leadership styles. The importance of the study to the current research is that it found that the nursing workforce can achieve better outcomes for patients by promoting relational leadership styles (Cummings, et al., 2010). The research conducted by Cummings, et al. (2010) will be especially useful in the current research as it examined the contribution of nursing leadership styles in hospitals with the extremely important indicator of patient 30-day mortality. Cummings et al. (2010) controlled for patient demographics, co-morbidities and institutional and hospital nursing characteristics, their research is robust and can be confidently used to account for the association between patient outcomes and nurse leadership styles. Because the researchers teased out attributes of leadership that center on collegial interactions among professionals, Cummings, et al. (2010) added to nurse leadership theory in a particularly important way. That is to say that the literature on leadership discusses a great many different attributes and behaviors of leaders, that it is crucial to be able to distinguish among those variables that are significantly related to patient outcomes. The finding that high-resonant styles (leaders with strong emotional intelligence characterized by relational qualities) nursing leadership contributed to a statistically significant 26% lower patient mortality rate when compared with the mixed leadership group is substantive and absolutely relevant to the current research topic.
In a slightly different approach to the study of nursing leadership, Cummings, et al. (2008) found that leadership styles that were relational or transformational achieved more positive outcomes for practicing nurses and resulted in more positive changes in their work environments than did task-focused leadership styles. Cummings, et al. (2008) examined outcomes commonly associated with job satisfaction and burnout, such as absenteeism, emotional exhaustion, job tension, organizational commitment, and turnover. The work environment outcomes Cummings, et al. (2010) studied are associated with higher levels of performance, and included better organizational climate, better nurse -- physician teamwork, better work team climates, greater empowerment, innovation, and, research utilization. In the research conducted by Wong and Cummings (2007), the emphasis was on patient outcomes, with the researchers looking closely at reductions in adverse events, reductions in complications, less mortality, and increases in patient satisfaction. The findings of the research conducted by Wong and Cummings (2007) were significant, thereby contributing to theory about the mechanisms by which leadership can influence patient outcomes.
Brady Germain and Cummings (2010) explored the influence of leadership factors on the perceptions nurses have of their performance motivation. Brady Germain and Cummings (2010) found that nurses tend to perceive that the factors that affect their ability and motivation to perform fall into five categories according to content analysis: these categories are autonomy, leadership practices, resource accessibility, and work relationships. The importance of this study and the way it most strongly supports the current research is that it has the potential to increase understanding by nurse leaders about which factors are most influential with respect to nurse practitioner performance and motivation can use that knowledge to improve nursing performance and higher quality patient care.
Sherman and Pross (2010) review and make recommendations about a competency model, Nurse Manager Leadership Collaborative Learning Domain Framework, that is a useful resource in the development of nursing leaders at the unit level, and that supports the ability of institutions and certification bodies to identify the abilities, knowledge, and skills needed for effective nursing leadership in the future. The nursing literature provides evidence that healthy work environments positively influence improved patient outcomes, organizational performance, and staff satisfaction. The establishment of a healthy work environment requires strong nursing leadership at all levels of an organization, but especially at the point of care or unit level where most front line staff work and patient care is delivered. This emphasis is strongly related to the direction that will be taken by the current research.
In their ex-post facto/correlational study, McNeese-Smith (1999) examined the relationships among the following variables: nurse manager motivation for power, achievement and affiliation, managerial leadership behaviors, staff nurse outcomes of job satisfaction, productivity and organizational commitment, and patient satisfaction. Their research found that the achievement motivation of nursing leaders is positively correlated with leadership behaviors and, importantly, with nurse job satisfaction, nurse productivity, and nurses' organizational commitment.
Luzinski (2011) asserted that the results of quality nurse leadership are evident in nursing practice at the patient's side, firmly aligning the investigation to the current research. Luzinski (2011) found that knowledgeable, strong, risk-taking nurse leaders follow a well-articulated, strategic, and visionary philosophy in the day-to-day operations of nursing services that results in improved patient outcomes, and that their behaviors convey a strong sense of advocacy and support for the staff and for the patient. Luzinski (2011) argued that nurse leaders demonstrating transformational leadership bring about meaningful improvements in the nursing practice environment and in quality, safety, and outcomes of patient care. Moreover, Luzinski (2011) asserted that transformational nurse leaders implement controlled destabilization in order to produce new ideas, innovation, get ahead of the rapid change in evolving healthcare systems, and ensure the most positive patient outcomes. With these two important findings, Luzinski (2011) underscored the importance of transformational nurse leadership in reaching desirable performance standards and in creating environments that conduct deep evaluations of their standard practices and policies in order to effect meaningful and informed change.
In their study of the indirect mechanisms by which leadership is related to outcomes, Rowen and Doyle (2003) suggest that a limitation of this line of research may be that nurse sensitive outcomes are too insensitive to change to be attributed to transformational leadership interventions within a hospital. The importance of this research is that it underscores the importance of ensuring that the outcome measures for intervention effectiveness elucidate the mechanisms by which interventions work.
Aiken, et al. (2014) assessed whether differences in patient-to-nurse ratios and nurses' educational qualifications in countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures. The number of surveys research participants was large (n = 26-516), and the primary dependent variable was the likelihood of surgical patients dying within 30 days of admission (Aiken, et al., 2014). The research findings indicate that an increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1•068, 95% CI 1•031 -- 1•106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0•929, 0•886 -- 0•973) (Aiken, et al., 2014). Aiken, et al. (2014) contributed to evidence-based practice that nurse staffing cuts to save money are likely to adversely affect patient outcomes, and contributed to nursing leadership theory through their finding that the percentage of hospital nurses with bachelor's degrees is associated with reduced patient deaths during hospital stays.
Spence Laschinger and Leiter (2006) sought to test a theoretical model of professional nurse work environments that linked to nursing practice burnout and, subsequently, to patient safety outcomes. The study is useful to the current research as it provides examples of how two instruments (Practice Environment Scale of the Nursing Work Index; Maslach Burnout Inventory-Human Service Scale) were used to gauge the perceptions nurses (Spence Laschinger and Leiter, 2006). The results suggest that patient safety outcomes are related to the quality of the nursing practice work environment and nursing leadership's role in changing the work environment to decrease nurse burnout (Spence Laschinger and Leiter, 2006).
Gunnarsdottira, et al. (2009) investigated aspects of nurses' work environments linked with job outcomes and assessments of quality of care in an Icelandic hospital. Importantly, Gunnarsdottira, et al. (2009) found that hospitals with high staff retention show supportive management, professional autonomy, good inter-professional relations and nurse job satisfaction, reduced nurse burnout, and improved quality of patient care. The researchers concluded that efforts to improve and maintain nurses' relations with nurse managers and doctors, as well as their perceptions of staffing adequacy, will likely improve nurse job satisfaction and employee retention, and may improve the quality of patient care Gunnarsdottira, et al. (2009).
Aiken, et al. (2008) analyzed the net effects of nurse practice environments on nurse and patient outcomes after accounting for nurse staffing and education. Data from 10,184 nurses and 232,342 surgical patients in 168 Pennsylvania hospitals were analyzed (Aiken, et al., 2008). Outcomes included nurse job satisfaction, burnout, intent to leave, and reports of quality of care, mortality, and failure to rescue in patients (Aiken, et al., 2008). Nurses reported more positive job experiences and fewer concerns with care quality, and patients had significantly lower risks of death and failure to rescue in hospitals with better care environments (Aiken, et al., 2008). The researchers concluded that nursing environments are highly influenced by leadership (Aiken, et al., 2008).
Aiken, et al. (2001) explored the current nursing shortage, reports of high hospital nurse job dissatisfaction, and reports of uneven quality of hospital care in five…