The Effect of Nurses' Leadership Behavior on the Quality of Nursing Care and Patient Outcomes

MATERIAL AND METHODS

Scanning

Two researchers accessed 4,111 items of data by scanning the abovementioned search engines based on the key words shown in Figure 2. The abstracts of 170 items whose titles or abstracts included any of the specified key words were examined; 26 study abstracts indicated the effect of leadership behaviors and/or leadership styles in nursing on the outcome of patient care and/or QNC. Studies whose full text could be accessed were examined for the inclusion criteria; 13 studies which met these criteria were selected for review. In order to ensure reliability between researchers, 411 items (10% of the total) were selected at random by a third researcher and examined with regard to the inclusion criteria; there was 100% agreement between evaluations. The inclusion process is summarized in Figure 2.

Figure 1.

Scanning for inclusion and exclusion criteria.

Adapted from: Wong, C. A., & Cummings, G. G. (2007). The relationship between nursing leadership and patient outcomes: A systematic review. Journal of Nursing Management, 15(5), 508–521.doi:10.1111/j.1365-2834.2007.00723.x.

FINDINGS

The results of 13 studies published between 1 January 2010 and 31 May 2016 were included in this review. The characteristics of the studies and the detailed examination are summarized in Table 1.

In the studies included in the research, an investigation was made of the effect of leadership styles or behaviors on patient mortality (Cummings et al., 2010); the QNC from the perspective of the nurses (Lavoie-Tremblay et al., 2016; Ma et al., 2015; Mendes & de Jesus José Gil Fradique, 2014; LaSchinger & Fida, 2015; Westerberg & Tafvelin, 2014; Wong et al., 2010); patient satisfaction (Boev, 2012); unwanted/adverse events (Wong & Giallonardo, 2013); health-care-associated infections (Agnew & Flin, 2014); management of pressure ulcers (Frumenti & Kurtz, 2014); the care indicators of falling, pressure ulcers, unwanted weight loss, and repeated admission to hospital (Jeon et al., 2015); drug errors, wrong management of feeding tubes, and inadequacies in daily nursing care (McKinney et al., 2016).

Figure 2.

Process of selection of studies for review.

DISCUSSION

This study focused on the relationship between nurse managers' leadership styles and behaviors, and QNC and patient outcomes. Most of studies using advanced analyses to define the relationship provided a strong contribution in determining the effect of leadership style on measurable indicators such as infection rate, mortality, patient satisfaction, adverse events, falls, and pressure ulcers (Lavoie-Tremblay et al., 2016; Schinger & Fida, 2015; Wong & Giallonardo, 2013; Wong et al., 2010). On the other hand, examinations of the relationship between leadership styles and QNC in which the results were based on nurse perceptions instead of measurable indicators were one of the most important limitations of the studies (Agnew & Flin, 2014; Boev, 2012; LaSchinger & Fida, 2015; Ma et al., 2015; McKinney et al., 2016; Mendes & de Jesus José Gil Fradique, 2014; Westerberg & Tafvelin, 2014).

In most of the studies, relationship-focused leadership behaviors were seen to make a more positive contribution to QNC and patient outcomes than task-focused leadership behaviors. Westerberg and Tafvelin (2014) found that the use of transformational leadership style had a positive effect on the work environment and, the leadership styles had indirect effectiveness on QNC. In a study by Jeon et al. (2015), the transformational leadership style acquired by training given to managers in care institutions for aged people had a direct effect on management support, leadership actions, behaviors, and effects, but there was not enough evidence that the transformation leadership style improved QNC and patient safety.

Frumenti and Kurz (2014) showed that transformational leadership style training given to managers had a positive effect; management of pressure ulcers was better in the experimental group than in the control group.

Similarly, Lavoie-Tremblay et al. (2016) found that transformational leadership style was associated with higher QNC, while an exploitative leadership style was associated with lower QNC. However, in a study by Hasemann (2004), authoritarian leadership was correlated with a higher QNC than nonauthoritarian leadership. Several studies found that transformational leadership style was associated with improved QNC indicators such as incidence of pressure ulcers and falls, and pain management (Anderson, Issel, & McDaniel, 2003; Castle & Decker, 2011; Forbes-Thompson, Leiker, & Bleich, 2007; Rask et al., 2007; Tippet, 2009). Agnew and Flin (2014) determined that units where nurse managers showed change-focused and relationship/support-focused leadership behaviors showed significant decreases in health-care-associated infections. In a systematic review covering the years 2005–2012, Wong et al. (2013) found that relationship-focused leadership styles such as transformational leadership were associated with reductions in rates of patient mortality, drug errors, health-care-associated infections, and hospital readmissions (Wong et al., 2013).

Wong et al. (2010) found that authentic leadership style had a positive effect on perceptions of QNC, through a reliable management and work environment. Wong and Giallonardo (2013) determined that authentic leadership style was significantly associated with reduced adverse patient outcomes, although in this study, factors such as staffing levels, patient status, and quality processes were not measured. Even when the relationship between leadership styles and QNC was examined only based on nurses' perceptions, these studies suggested that leadership styles could have a significant impact on QNC (Mendes & de Jesus José Gil Fradique, 2014). In a study by Spence LaSchinger and Fida (2015), the authentic leadership style was directly associated with increased QNC and with supported nurses' competence, enabling them to use effective professional practice in patient care. In a study by Mendes and de Jesus José Gil Fradique (2014), an increase in nurse managers' recognition, communication, team development, and innovation leadership behaviors was associated with an increase in QNC.

Cummings et al. (2010) studied the effect of resonant versus dissonant leadership styles, with a very large sample size, and variables such as patient demographics, comorbidities, and institutional and hospital nursing characteristics kept constant. They found that in hospitals where a highly resonant leadership style was applied, patient mortality rates were significantly lower than in hospitals where other leadership styles were practiced. Boev (2012) found that a positive perception of nurse managers' leadership skills and behaviors by staff nurses was significantly associated with increased patient satisfaction. Although the study's sample size was small and the psychometric properties of the patient satisfaction instrument were not examined, this study provides preliminary support for the relationship between positive perception of nurses toward their nurse manager and the level of patient satisfaction. Ma et al. (2015) found that when nurse leaders cooperated with nurses providing patient care, nurses' work satisfaction increased, turnover decreased, and QNC indicators improved. Vogus and Sutcliffe (2007) reached similar conclusions: the presence of nurse leaders who were trusted by the team was associated with appreciably reduced rates of medical errors. In a study examining the effect of managers' leadership styles on QNC indicators including drug errors, inadequacies in daily patient care, and wrong management of feeding tubes, consensus leadership was found to be strongly correlated with quality-of-care deficiency odds compared to consultative, autocratic, and participatory leadership styles (McKinney et al., 2016).

In a systematic review examining the effects of leadership behaviors and styles on patient outcomes covering the years 1985–2005 (Wong & Cummings, 2007), positive leadership behaviors and styles or practices such as communication openness, formalization, participation in decision-making, and relationship-orientated leadership were associated with increased patient satisfaction and reduced incidence of adverse events compared to transactional or task-oriented leadership styles. In addition, interactive leadership was associated with increased patient satisfaction; positive leadership behaviors by managers and an increase in team expertise and in staff retention was associated with lower patient mortality rates. Nurses' participation in the decision-making process and management by experienced nurses were associated with reduced incidence of adverse events. An increase in open communication and management by experienced nurses were associated with reduced rehospitalization rates. An increase in team expertise was associated with reduced rates of health-care-associated infections (Wong & Cummings, 2007).

CONCLUSION

The practice of effective styles or behaviors of leadership in nursing management in institutions providing health services can influence increases in QNC and optimal patient outcomes. Compared to task-focused leadership behaviors, relationship-focused leadership behaviors such as the transformation leadership style are associated, whether directly or indirectly, with improved patient outcomes and higher QNC.

There is a need for descriptive studies to determine the effect of nursing management leadership behaviors or styles on patient outcomes and QNC indicators such as mortality rates, incidence of pressure ulcers and health-care-associated infections, and patient satisfaction, and to test these styles or behaviors in clinical environ-ments.

Disclosure

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

Funding

The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.