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



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.
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This article is not for distribution
Nursing Times [online] August 2017 / Vol 113 Issue 8
Keywords Leaders/Team/Motivation/
This article has been
double-blind peer reviewed
What is the best approach to
nurse leadership – if there
is such a thing? What evi-
dence is there on the effec-
tiveness of different leadership styles?
Despite overwhelming interest in leader-
ship within the profession, there is surpris-
ingly 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 con-
trast between transactional and transfor-
mational 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 transforma-
tional leadership is a motivational model
Good nurse
leadership can
have a positive
impact on both
patient experience
and outcomes, and
nurse satisfaction
and retention
– traditionally
undesirable – has
been shown to
improve patient
It is the nature of
the relationship
between leaders and
followers, rather
than any specific
behaviours of
leaders, that
produces eective
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
where leaders seek to trigger motivation in
individuals rather than get them to under-
take a particular task. Bass and Avolio
(1990) describe transformational leader-
ship as the four ‘i’s:
l Individualised consideration –
identifying the needs of individual
members of staff;
l Intellectual stimulation – question the
status quo and present new ideas;
l Inspirational motivation – present a
vision in which people can achieve
their personal goals through meeting
the organisation’s goals;
l Idealised influence – role model the
Burns’ original work is often presented
rather crudely as a stark choice between
transactional and transformational leader-
ship, 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
Good leadership in nursing:
what is the most effective approach?
Author Elaine Maxwell is associate professor in leadership, School of Health and
Social Care, London South Bank University.
Abstract 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 dierent leadership theories, describing how they can
be applied to nursing and how eective they are. What emerges is that dierent
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 eective
approach? Nursing Times [online]; 113: 9, 18-21.
In this article...
l Dierent theories and models of leadership
l Evidence around the eectiveness of nurse leadership styles
l Key skills that nurse leaders need to develop
Nursing Practice
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Nursing Times [online] August 2017 / Vol 113 Issue 8
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 leader-
ship – to name but a few.
Avolio, who had worked with Bass on
transformational leadership, developed
his thinking further into authentic leader-
ship, 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 leader-
ship, 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 situa-
tional leadership model.
Impact on patient outcomes
There is some evidence that resonant lead-
ership 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
suggest that it is the nature of the relation-
ship between them, rather than any spe-
cific behaviours of leaders, that produces
effective leadership.
Hersey and Blanchard (1969) observed
that the leader’s actions should be deter-
mined by the maturity of the team and that
the behaviours of good leaders are situa-
tional 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, sug-
gesting 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), suc-
cessful leadership is achieved by articu-
lating 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
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? Hutch-
inson and Jackson (2013) argue that the
flaws in how transformational leadership
has been researched in nursing mean that
“new ways of thinking about nursing lead-
ership 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 transforma-
tional 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 evalu-
ated their own professional skills as excel-
lent and felt their leaders’ support for pro-
fessional 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 out-
comes, and nurse satisfaction and reten-
tion. There is some suggestion that the
latter then influences the former. However,
determining what makes good nurse lead-
ership is challenging.
In the face of ambiguity and com-
plexity, it seems that good leadership is
nuanced and requires careful considera-
tion. Where there are apparently contra-
dictory 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
Nursing Practice
Good leadership is nuanced and requires careful consideration
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Nursing Times [online] August 2017 / Vol 113 Issue 8
proposed by Laschinger et al (2014), posi-
tive 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 develop-
ment 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 prac-
tise 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.
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, Medi-
terranean countries and the USA regarding
perceptions of control over practice, but
none regarding intrinsic work motivation.
Futher evidence of the universal appli-
cation 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 accept-
able internal consistency scores. Interest
in measuring the practice environment in
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 turn-
over 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 motiva-
tion to work. They proposed that the rea-
sons for job satisfaction are intrinsic – that
is, based on how the job makes workers
feel. However, the reasons for dissatisfac-
tion are extrinsic – for example, dissatis-
faction with the material rewards that
come with the job. Job satisfaction, they
claim, is linked to empowerment and a
sense of achieving personal and profes-
sional 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 relation-
ships with nurse leaders. It was even lower
where nurses also felt they had good rela-
tionships 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
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 medi-
cation 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 pro-
ject 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:
l The level of registered nurse
participation in clinical decision-
making accounted for 15% of the
variance in clients’ aggressive and/or
disruptive behaviour problems;
l The level of transparency accounted for
21% of the variance in use of restraints;
l 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 con-
trast, Havig et al (2011) found a significant
positive association between a task-ori-
ented leadership style of nursing home
ward managers and the families’ satisfac-
tion with resident care. Doran et al (2004)
found that a transactional leadership style
was related to increased patient satisfac-
tion, 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 rela-
tionships 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 influ-
ence on nurse morale and retention.
Nursing Practice
For more articles
on leadership, go to
5.1% Variance in 30-day
mortality between nine
hospitals explained by
dierent leadership styles
Box 1. Five key elements of a
professional practice model
lProfessional values
lProfessional relationships
lPatient care delivery system
lManagement approach
lCompensation and rewards structure
Source: Hoart and Woods (1996)
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This article is not for distribution
Nursing Times [online] August 2017 / Vol 113 Issue 8
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Australia was also shown by Flint et al
(2010), who validated the Brisbane Practice
Environment Measure.
The elements of the different profes-
sional 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 lead-
ership? 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:
l To the task at hand – which may require
a transactional approach;
l To the needs of the team – which may
require a transformational approach;
l To the pivotal requirement of building
and maintaining productive
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 circum-
stances, flexible enough to respond to the
reactions of the team, and agile enough to
deal with the unexpected. NT
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For more on this topic go online...
lFrom leader to leadership in
emergency care
Box 2. Four key skills of
nurse leaders
lMonitoring and calibrating the
team’s workload
lCreating a work environment
in which all sta feel they can
contribute the maximum in a fulfilling
way for them
lCreating relationships that build
lEnsuring that the team deliver safe
care, good experience (for patients
and for sta) and the best use of
available resources
“The evidence suggests that
nurse leaders should adapt
their leadership behaviours”
... Nurse leaders should have diverse knowledge that, in addition to technical skills, includes management and leadership abilities [38]. Nurse managers, in addition to utilizing the skills learned, must also develop the ability to adapt their leadership behaviors [39]. Without adequate and trusting leadership, no group can achieve its goals, it would be no different with nurses that depend on their leaders to acquire new knowledge and skills and also to have a work environment where they feel satisfied. ...
Full-text available
Nursing leadership directly affects the success of health institutions, as attitudes of nurse leaders will reflect on staff nurses' job satisfaction and, consequently, on the quality of care. It is necessary to emphasize that care is the basic talent of nursing, therefore, when performing their duties as leaders; nurses must focus on their main objective, which is to guarantee the quality of care. Nurse managers can adopt several leadership styles while leading their teams, but transformational leadership seems to be the most suitable for nurses. The purpose of this study was to explore the transformational leadership style in the field of nursing. This is a bibliographical and descriptive study. Search for articles was conducted in the Scopus database using the descriptors: "Transformational leadership" and "Nursing" using the Boolean Operator "AND". A total of 12 articles were included. Transformational leaders are innovative, creative, and visionary; they seek to empower their followers through personal and professional development. Staff nurses and nurse managers get more satisfied when transformational leadership is adopted. It was observed that nurses who received more training in leadership are more supporters of transformational leadership practices. Thus, nurses should receive adequate leadership training in nursing schools and the subject should also be addressed in continuing education programs in health institutions.
Nursing organizations and leaders within the profession define nurse leader in multiple ways. The goal of this article is to present a new definition of nurse leader that can be adopted by all nurse professionals across practice continuums and globally. Included is a description of the rationale behind proposing this new definition, the process used by board members of the Texas Organization for Nursing Leadership and the Nurse Leader Definition Task Force to create the new definition of a nurse leader.
ResearchGate has not been able to resolve any references for this publication.