This literature review synthesizes research on nursing leadership styles and their effects on patient outcomes, nurse performance, and work environments. Drawing on studies by Cummings and colleagues, Aiken and colleagues, and other nurse leadership researchers, the paper examines how relational and transformational leadership styles outperform task-focused approaches across a range of outcomes, including patient mortality, nurse job satisfaction, burnout, and organizational commitment. The review also addresses the influence of nurse staffing ratios, educational qualifications, and practice environment quality on patient safety. Together, the studies confirm that strong, visionary nursing leadership at all organizational levels is central to achieving high-quality, safe patient care.
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 this study to current research is that it found that the nursing workforce can achieve better outcomes for patients by promoting relational leadership styles. This research is especially useful because it examined the contribution of nursing leadership styles in hospitals using the critically important indicator of patient 30-day mortality. By controlling for patient demographics, comorbidities, and institutional and hospital nursing characteristics, Cummings et al. (2010) produced robust findings that can be confidently used to account for the association between patient outcomes and nurse leadership styles.
Because the researchers identified attributes of leadership centered on collegial interactions among professionals, Cummings et al. (2010) advanced nurse leadership theory in a particularly important way. The leadership literature discusses a great many different attributes and behaviors of leaders, making it crucial to distinguish among those variables that are significantly related to patient outcomes. The finding that high-resonant leadership styles — characterized by strong emotional intelligence and relational qualities — contributed to a statistically significant 26% lower patient mortality rate when compared with a mixed leadership group is substantive and directly relevant to this line of research.
In a related but distinct approach to studying nursing leadership, Cummings et al. (2008) found that relational or transformational leadership styles 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, including absenteeism, emotional exhaustion, job tension, organizational commitment, and turnover. The work environment outcomes studied are associated with higher levels of performance and included better organizational climate, improved 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 examining reductions in adverse events, reductions in complications, decreased mortality, and increases in patient satisfaction. The findings of Wong and Cummings (2007) were significant, thereby contributing to theory about the mechanisms by which leadership influences patient outcomes.
Luzinski (2011) asserted that the results of quality nurse leadership are evident in nursing practice at the patient's bedside. Luzinski (2011) found that knowledgeable, strong, risk-taking nurse leaders follow a well-articulated, strategic, and visionary philosophy in day-to-day nursing operations, resulting in improved patient outcomes, and that their behaviors convey a strong sense of advocacy and support for both staff and patients. Luzinski (2011) argued that nurse leaders who demonstrate transformational leadership bring about meaningful improvements in the nursing practice environment and in the quality, safety, and outcomes of patient care. Moreover, Luzinski (2011) asserted that transformational nurse leaders implement controlled destabilization in order to generate new ideas and innovation, stay ahead of rapid change in evolving healthcare systems, and ensure the most positive patient outcomes. These findings underscore the importance of transformational nurse leadership in reaching desirable performance standards and in creating environments that conduct deep evaluations of standard practices and policies in order to effect meaningful, 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 directly attributed to transformational leadership interventions within a hospital. The importance of this research lies in its emphasis on ensuring that outcome measures for intervention effectiveness adequately elucidate the mechanisms by which interventions work.
Brady Germain and Cummings (2010) explored the influence of leadership factors on nurses' perceptions of their performance motivation. They found that nurses tend to perceive the factors affecting their ability and motivation to perform as falling into five categories, identified through content analysis: autonomy, leadership practices, resource accessibility, and work relationships. This study is particularly important because it has the potential to increase nurse leaders' understanding of which factors most strongly influence nurse practitioner performance and motivation, knowledge that can in turn be used to improve nursing performance and deliver higher quality patient care.
Sherman and Pross (2010) reviewed and made recommendations about a competency model — the Nurse Manager Leadership Collaborative Learning Domain Framework — as a useful resource for developing nursing leaders at the unit level. This model 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 frontline staff work and patient care is delivered.
In their ex-post facto correlational study, McNeese-Smith (1999) examined the relationships among nurse manager motivation for power, achievement, and affiliation; managerial leadership behaviors; and staff nurse outcomes of job satisfaction, productivity, and organizational commitment. 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.
"Nurse-to-patient ratios and degrees linked to mortality rates"
"Work environment quality mediates burnout and patient safety"
Luzinski, C. (2011, December). Transformational leadership. Journal of Nursing Administration, 41(12), 501–502. doi:10.1097/NNA.0b013e3182378a71
McNeese-Smith, D. K. (1999). The relationship between managerial motivation, leadership, nurse outcomes and patient satisfaction. Journal of Organizational Behavior, 20(2), 243–259. doi:10.1002/(SICI)1099-1379(199903)20:2<243::AID-JOB888>3.0.CO;2-2
Rowen, L., & Doyle, K. (2003, March 5). A comparison of leadership development interventions: Effects on nurse and patient outcomes. Paper presented at the University Medical Center.
Sherman, R., & Pross, E. (2010, January 31). Growing future nurse leaders to build and sustain healthy work environments at the unit level. OJIN: The Online Journal of Issues in Nursing, 15(1), Manuscript 1. doi:10.3912/OJIN.Vol15No01Man01
Spence Laschinger, H. K., & Leiter, M. P. (2006). The impact of nursing work environments on patient safety outcomes: The mediating role of burnout/engagement. The Journal of Nursing Administration, 36(5), 259–267.
Wong, C. A., & Cummings, G. G. (2007). The relationship between nursing leadership and patient outcomes: A systematic review. Journal of Nursing Management, 15, 508–521. doi:10.1111/j.1365-2834.2007.00723.x
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