In the challenge to improve patient care outcomes, attract and retain top-performing staff, and effectively prepare for patient care needs, effective nursing leadership is critical to advance agendas for change.
Effective nurse leaders ensure that the appropriate manpower and resources are in place to achieve optimal care quality and patient outcomes. At the organizational level, nurse administrators contribute to strategy setting through their involvement in senior level decision-making and their ability to influence how nursing is practiced and perceived.
The purpose of this study was to describe the findings of a systematic review of studies in the literature that examine the relationship between nursing leadership practices and patient outcomes. In a previous review, a search in electronic databases for the years between 1985 and 30 April 2005 found only seven studies examining the relationship between nursing leadership and patient outcomes. In this review, the evidence was updated by adding the results of studies published between 1 May 2005 and 31 July 2012. From an online database yield of 20,383 potentially relevant titles, 13 titles met the relevant search criteria. All 20 studies were published between 1999 and July 2012 and all but five were conducted in the United States, the others being conducted in Canada and Norway.
A conceptual framework for the study review was developed based on a structure-process-outcome (SPO) framework to examine the linkages between leadership and patient outcomes. Three conceptual domains comprise this framework:
- Structure, which is concerned with organizational or setting factors
- Process, which is concerned with mechanisms for coordinating and facilitating patient care
- Outcomes of care
The SPO framework has been used extensively in examining relationships among organizational structural features such as nurse staffing or leadership and nurse and patient outcomes.
We isolated the leadership style of nurse leaders in organizations as structure. Leadership was defined broadly as “the process through which an individual attempts to intentionally influence another individual or a group in order to accomplish a goal”. We further categorized two leadership styles.
Relationally orientated – an approach that focuses on people and relationships.
- Shows concern and respect for followers, expresses appreciation and support, and is genuinely concerned for their welfare
- Followers have trust and respect for the leader and are motivation to go above and beyond to achieve organizational goals (transformational leadership)
Task orientated – achieves common goals or has styles which focus on structures and tasks.
- Defines and organizes the roles of followers, concerned with goals, procedures and production, establish well-defined lines of communication
- Likely to keep their distance psychologically from their followers
- Emphasizes the transaction or economic exchange that takes place among leaders, colleagues and followers to accomplish work. The transactional leader's role is primarily that of recognizing follower needs and monitoring their role fulfilment (transactional leadership)
- Transactional leaders facilitate patient care by providing direction, clarification of tasks and clear work expectations
The process concept was defined as the leadership processes or mechanisms by which leaders may contribute to patient outcomes. Examples of these processes may include facilitating work conditions that promote optimum safe patient care, creating open communication with staff to support quality care standards, or promoting positive relationships with staff that promote work engagement.
Outcome considers the measurable results of care and we focused exclusively on patient outcomes. These were defined as outcomes describing patient mortality, patient safety outcomes such as the incidence of adverse events involving patients or complications during hospitalization, patient perceptions of satisfaction with care, and healthcare utilization such as length of stay.
The Relationship Between Leadership and Patient Outcomes
In this review 19 patient outcome variables were found, which were grouped into five categories using content analysis. These showed the relationship between leadership and:
- Patient satisfaction
- Patient mortality, patient safety outcomes
- Adverse events
- Patient healthcare utilization
In 30% of studies, patient outcomes, primarily patient or family satisfaction, were collected prospectively by researchers. In one study, patient mortality and complications were collected from clinical charts and in all other studies patient outcomes were collected from administrative databases. Of the individual outcomes, patient mortality and medication errors were the most frequently examined outcomes. Over all studies, a total of 43 relationships between leadership and patient outcomes were examined and 63% of these were significant. While 26 relationships between leadership and positive patient outcomes were significant, one relationship showed the opposite of the expected results.
The number of studies relating leadership practices to patient satisfaction was more than doubled in this review. The results showed significant associations between leadership and increased patient satisfaction in four studies. Relational leadership was associated with patient satisfaction in two studies, while another found that family satisfaction with resident care was significantly and positively related to task-oriented leadership style of nursing home ward managers. Similarly, others found that the transactional leadership style was related to increased patient satisfaction.
In four of six studies, leadership was significantly associated with patient mortality. Transformational and resonant leadership were associated with lower patient mortality in three studies while, contrary to hypothesis, leadership was associated with higher mortality in one study. It has been suggested that managers with larger spans of control may have been hampered in their ability to provide direct support to nursing staff. However, there was another contradictory finding in that lower mortality was associated with higher nurse burnout.
Patient Safety Outcomes: Adverse Events
A total of nine studies addressed ten types of outcomes in this category. The strongest relationship was between leadership and medication errors, as four of five studies showed significant negative relationships. Transformational leadership, manager support and trust in leadership were all associated with lower medication errors. Patient falls were examined in four studies and the results were mixed since two studies showed significantly decreased patient falls related to transformational leadership, while in two other studies manager support was not significantly related to fall rates. A lower incidence of pressure ulcers was significantly associated with leadership in only one of three studies. Two studies found significant relationships between positive leadership styles (consensus and participative) and lower restraint use in nursing homes. In two of three studies examining hospital-acquired infections (pneumonia and urinary tract infections) transformational leadership was associated with lower infection rates.
Patient Safety Outcomes: Complications
Three types of complication outcomes were addressed in two studies and thus there were few studies for each type of complication limiting the ability to draw conclusions. A study conducted in neonatal intensive care settings found a reduced incidence of neonatal periventricular haemorrhage/periventricular leukomalacia (PIVH/PVL) associated with higher leadership ratings. No relationship between leadership and pulmonary embolism/deep vein thrombosis was found.
Patient Healthcare Utilization
A new category of patient outcomes was added since three studies addressed patient healthcare utilization indicators, specifically the number of hospitalizations, hospital readmissions and hospital length of stay as outcomes related to work environment factors including leadership. Healthcare utilization measures reflect services or resources consumed in managing patients' health-related needs. It has been proposed that patient hospitalizations are considered important indicators of the general health status of patients who are on dialysis and may be considered a reasonable nurse-sensitive quality indicator in dialysis settings. One study claimed that the frequency of hospital readmission rates reflected an inadequate patient safety process which means that hospitals with poorer safety cultures would be expected to exhibit higher levels of hospital readmissions. Manager support was included as one element of patient safety culture. Both studies did not demonstrate significant findings for the effects of leadership on these two healthcare utilization outcomes. However, it was found that manager support was associated with a lower patient length of stay through the human resource indicators of lower absenteeism, overtime and nurse to patient ratio.
Discussing the Impact of Relational Leadership
The findings provide support for the assertion that relational leadership practices are positively associated with some categories of patient outcomes. They highlighted a key relationship between relational leadership and the reduction of adverse events, specifically medication errors, possibly through leaders' influence on human resource variables that may be connected to patient care outcomes, staff expertise, turnover, absenteeism, overtime and nurse to patient ratios. This important connection may suggest that effective nursing leadership is essential to the creation of nursing work environments, with appropriate staffing levels, resources and care processes that support nurses in preventing unnecessary deaths. Finally, there was a significant positive relationship between both relational and task-oriented leadership and patient satisfaction. This finding may indicate that some elements of each style are needed to ensure care processes that contribute to satisfied patients such as clear standards of care and role expectations as well as collaborative working relationships.
Implications for Leadership Theory
Transformational leadership was the most frequently applied leadership theory in the reviewed studies. Attention to other leadership theories that may have relevance to nursing and healthcare are worthy of further application for the potential mediating processes they propose between leadership and outcomes.
Authentic leadership is an emergent leadership approach from the field of positive organizational behavior that highlights the importance of examining the context and the influence of followers in the leader-follower dynamic. This relational leadership approach is grounded in the leader's positive psychological capacities, honesty and transparency, strong ethics and behavioral integrity. The utility of this theory is that it emphasizes possible mechanisms through which leadership influences performance, and how followers shape leadership within and between various organizational contexts, climates and cultures.
Resonant leadership theory, based on the concept of emotional intelligence, is also worthy of greater application in healthcare. These theories focus on the leader's ability to attend to the individual's emotions and the outcomes of these behaviors for individual's well-being and performance. Likewise, leader-member exchange (LMX) theory has received little attention in healthcare despite a large empirical base in other disciplines and the potential to increase understanding of the linkages between leadership, processes and patient outcomes. In this theory, the nature and quality of the relationship between the leader and the follower that forms over time is posited to play a vital role in employee responses to their work environments.
Implications for Nursing Practice
The findings from this review underscore the value of relational leadership styles, which were positively and indirectly related to nurse's motivation to perform, improved work environments and outcomes for nurses and nurse retention. These findings suggest that a complex interplay of associations between the relational practices of formal nursing leaders to provide vision, support, staffing resources and leadership, with the health, competencies, abilities, knowledge, skills and motivation of nurses, are integral to the achievement of better patient outcomes.
Relationally-oriented leaders contribute to positive practice settings and staff work engagement by providing support and encouragement, positive and constructive feedback, open and transparent communication and individual consideration. Creating opportunities for meaningful dialogue between leaders and clinical nurses is necessary to discuss patient care issues that could impede patient safety. While this is challenging in the current high-paced, and heavy meeting-laden managerial roles, it remains a priority that cannot be overlooked. Nurses must be provided with the opportunity and staffing resources to monitor patients' conditions and address their education needs regarding self-care, symptom management and other factors related to patient empowerment.
The connection noted between supportive leadership styles and positive patient safety outcomes may point to the importance of unit leaders' understanding of patient care processes and the role of nurses and other healthcare providers in promoting better outcomes. A recent study provided evidence that when leaders demonstrated higher relational leadership, the staff on their units reported more positive patient safety climates. The ability of leaders to promote a safe workplace is governed by their knowledge of patient care needs, their level of relational skills and their capacity to recognize and implement effective safety practices. Additionally, the development of safety cultures through leadership interventions, which include managers' interdisciplinary walkabout safety rounds, have been linked to improved outcomes.
The Importance of Nursing Leadership
The current evidence reinforced findings from the previous review with respect to the positive relationships between relational leadership styles and patient satisfaction and improved patient safety outcomes. Specifically, the current evidence suggests a clear relationship between relational leadership styles and lower patient mortality and reduced medication errors, restraint use, and hospital-acquired infections. Thereby, recruiting and retaining individuals into leader roles with the requisite emotional intelligence competencies that underpin relational leadership styles are critical to effective performance at all levels of organizations.
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Adapted from: Wong, C.A., Cummings, G.G. & Ducharme, L. (2013) The relationship between nursing leadership and patient outcomes: a systematic review update. Journal of Nursing Management 21 (5), 709–724. [WWW document] URL http://onlinelibrary.wiley.com/doi/10.1111/jonm.12116/abstract [accessed 1 July 2014]