Journal of Health Services Research & Policy >
Volume 13, Number 4 >
Pp. 240-248
Review |
Faculty of Nursing, University of Alberta, Alberta;
1 Bonnyville Health Centre;
2 School of Nursing, University of Western Ontario, Canada
Correspondence to: gretac{at}ualberta.ca
Objectives: Leadership practices of health care managers can positively or negatively influence outcomes for organizations, providers and, ultimately, patients. Understanding the factors that contribute to nursing leadership is fundamental to ensuring a future supply of nursing leaders who can positively influence outcomes for health care providers and patients. The purpose of this study was to systematically review the multidisciplinary literature to examine the factors that contribute to nursing leadership and the effectiveness of educational interventions in developing leadership behaviours among nurses.
Methods: The search strategy began with 10 electronic databases (e.g. CINAHL, Medline). Published quantitative studies were included that examined the factors that contribute to leadership or the development of leadership behaviours in nurse leaders. Quality assessments, data extraction and analysis were completed on all included studies.
Results: A total of 27,717 titles/abstracts were screened resulting in 26 included manuscripts reporting on 24 studies. Twenty leadership factors were examined and categorized into four groups – behaviours and practices of individual leaders, traits and characteristics of individual leaders, influences of context and practice settings, and leader participation in educational activities. Specific behaviours and practices of individual leaders, such as taking on or practising leadership styles, skills and roles, were reported as significantly influencing leadership in eight studies. Traits and characteristics of individual leaders were examined in six studies with previous leadership experience (three studies) and education levels (two of three studies) having positive effects on observed leadership. Context and practice settings had a moderate influence on leadership effectiveness (three of five studies). Nine studies that examined participation in leadership development programs all reported significant positive influences on observed leadership.
Conclusion: These findings suggest that leadership can be developed through specific educational activities, and by modelling and practising leadership competencies. However, the relatively weak study designs provide limited evidence for specific factors that could increase the effectiveness of current nursing leadership or guide the identification of future nurse leaders. Robust theory and research on interventions to develop and promote viable nursing leadership for the future are needed to achieve the goal of developing healthy work environments for health care providers and optimizing care for patients.
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Effective nursing leadership provides guidance for solving complex problems related to nursing care delivery.8 Nurse leaders create structure, implement processes for nursing care and facilitate positive outcomes.9 With a forthcoming shortage of nursing leaders compounded by the current shortage of nurses, it is increasingly important to find ways to develop and retain nursing leaders to ensure positive outcomes in the health care system.10,11 Developing nursing leaders and recruiting and retaining staff nurses into leadership positions12 are essential components of succession planning for future nursing leadership.13 Health care organizations spend considerable resources every year on personnel and leadership development, so understanding the factors that contribute to nursing leadership is imperative. The purpose of this review was to describe the findings of a systematic review of studies that examine the factors that contribute to enhancing nursing leadership and to make recommendations for further study.
After completing an initial scoping review of the nursing leadership development literature, we found two main themes. A larger group of studies examined factors contributing to enhancing nursing leadership using predominantly correlational survey designs and a smaller number of studies examined the effectiveness of educational interventions to develop leadership behaviour using quasi-experimental pre/post designs. From that scoping review, two research questions were developed that guided the full systematic review:
| Methods |
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TopIntroductionMethodsResultsDiscussionConclusionAcknowledgementsReferences |
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The search strategy began with ten electronic databases: CINAHL, Medline, PsychInfo, ABI, ERIC, Sociological Abstracts, Embase, Cochrane, Health Star and Academic Search Premier. Keywords used included ‘leadership’, ‘research’, ‘evaluation’ and ‘measurement’, to find studies published between 1985 and December 2006 that examined factors contributing to nursing leadership. See Appendix 3 (www.jhsrp.rsmjournals.com/cgi/content/full/13/4/240/DC1) for search strategy.
Titles, abstracts and manuscripts were included if they met all inclusion criteria: (1) peer-reviewed research; (2) studies that measured leadership by nurses; (3) studies that measured one or more factors contributing to nursing leadership; and (4) studies that examined the relationship between these factors and nursing leadership. This excluded qualitative studies and grey literature.
Each abstract was reviewed twice for inclusion. Studies meeting inclusion criteria were categorized into nursing, other professions (such as medicine, teachers, etc.) and other settings (such as business, military or education). Due to the large volume of abstracts and only English language proficiency in our research team, we focused only on nursing studies published in English. All nursing studies were sorted into those that examined: (a) factors contributing to nursing leadership; (b) outcomes associated with nursing leadership; and (c) the measurement of leadership in nursing. The latter studies comprise two additional systematic reviews (submitted for publication).
The following data were extracted from included studies: author, journal, country, research purpose/questions, theoretical framework, design, setting, subjects, sampling method, measurement instruments and their reported reliability and validity, analysis, leadership measures, factors contributing to nursing leadership and significant/non-significant results. Two research team members completed and checked each data extraction.
Each published article was reviewed twice for methodological quality by two team members using a quality assessment tool was adapted from several previously published systematic reviews.1,14–16 The adapted tool (Appendix 1, see www.jhsrp.rsmjournals.com/cgi/content/full/13/4/240/DC1) was used to assess four areas of each study: research design, sampling, measurement and statistical analysis for a total of 14 possible points assigned from 13 criteria. Twelve items were scored as 0 ( = not met) or 1 ( = met) and one item related to the measurement of leadership was scored as 2 ( = objective observation), 1 ( = self-report) and 0 ( = not met). Based on assessed points, each study fell into one of three categories: high (10–14), medium (5–9) and low (0–4).
Studies that reported on implementation of an educational intervention to develop leadership skills were assessed using a pre/post quality assessment tool adapted from another published systematic review.15,17 The adapted tool (Appendix 2, www.jhsrp.rsmjournals.com/cgi/content/full/13/4/240/DC1) was used to assess six areas of each study: sampling, design, control of confounders, data collection and outcome measurement, statistical analysis and study dropouts. Thirteen items comprised the tool for a total of 16 points.
The primary author reviewed and approved all quality assessments, data extractions and analyses.
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The electronic database search yielded over 27,717 titles and abstracts. Following removal of duplicates, 18,963 titles and abstracts were screened using the inclusion criteria and 1278 manuscripts were retrieved. Of these, 141 were specific to nursing. Following quality assessment, 23 low quality correlational and exploratory/pilot studies were removed, leaving 118 nursing leadership studies. After final selection using the inclusion criteria for this review, 26 manuscripts (reporting 24 studies) were identified as examining the factors contributing to nursing leadership. Cunningham et al.18,19 and Tourangeau11,20 each had two included papers that reported on one study. The final 24 included quantitative studies and their characteristics are presented in Appendix 4 (see www.jhsrp.rsmjournals.com/cgi/content/full/13/4/240/DC1).
Sixteen of the 24 studies were conducted in the United States, two in Canada, one study in England and two had no country stated. For these two studies, the USA was assumed to be country of origin as their authors were located here.
The most common weaknesses in the 24 quantitative study designs related to sampling, design and analysis (Tables 1 and 2). Fifteen of the final 24 studies using correlational, non-experimental, cross-sectional or exploratory designs were rated as moderate or high (scores 
5). However, these correlational designs limit interpretations of causality. The remaining nine studies used pre/post implementation (quasi-experimental) designs and were rated as low quality (scores < 0.60). None of these studies used a control group for comparison. Comparisons were made only within each sample before and after the educational intervention to assess for a change in leadership behaviours. Despite the low ratings, this group of studies contained valuable information on the development of nursing leadership and were retained. Only seven of the 24 included studies used probability sampling, partially due to the difficulty in using random sampling methods to study leadership in specific individuals or units. As these studies must target leaders and their followers, convenience sampling may be used more frequently. Most studies used correlational and regression analyses and 16 studies failed to report the management of outliers. Only one study addressed appropriateness of sample size and three addressed anonymity of respondents. Seventeen studies used samples from more than one site.
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Factors contributing to nursing leadership
The 24 included studies investigated relationships between various factors (20 different factors in total) and nursing leadership, primarily in acute care settings. Using content analysis, we categorized these factors into four groups based on similar themes: behaviours and practices of individual leaders, traits and characteristics of individual leaders, influences of context and practice settings, and leader participation in educational activities to develop leadership (Table 3).
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This category included eight studies that described factors contributing to nursing leadership that our research team conceptualized as arising from the conscious, purposeful actions or decisions of leaders.21–27 Jenkins and Ladewig23 reported how demonstrating and practising leadership skills increased leadership behaviours in both leaders and nurses who worked for those leaders. Initiating structure and consideration, as well as role-taking (often linked to cognitive empathy) were also significantly related to leadership effectiveness26,27 and the use of situational leadership.27 Relationship-based competencies were reported as more important than financial and technical competencies for leadership effectiveness.25,28 This was supported by Goldenberg's work21 where most leaders used a low task and high relationship style.
Seven studies reported on relationships between specific traits and characteristics of nurse leaders and their reported leadership practices.22–24,28–31 Previous leadership experience was related to higher reports of a leader's skills and practices in three studies,22,23,30 although length of time in the present position was negatively correlated with leadership effectiveness.22 More effective leaders also had personality traits of openness, extroversion and motivation to manage.28 Significant positive relationships were reported between the leaders' motivation and their leadership behaviours.29,32 While motivation was significant, no particular style of motivation (such as socialized power or personalized power) led to increased leadership effectiveness. Age was positively related to leadership skills.24 These studies reported that older and more experienced nurses were more effective leaders. Value congruence between the leader and the organization was also not a significant predictor of leadership behaviour.30 Only one included study examined the influence of sex roles or gender as other studies in this area were removed due to low quality. That study found no significant relationship between sex role behaviour, gender and leadership style or effectiveness.31
This category consisted of six studies that examined the influence of context and differentiated practice settings on the behaviours of nursing leaders (Table 4).27,32–36 The results in this category were predicated on contact between leaders and employees as factors contributing to enhancing nursing leadership. One study explored changes in the practice setting which increased the distance between supervisor and caregivers.33 When staff had less contact with the leader, reported leader effectiveness decreased due to removing the influence of social emotional leadership. Nurses also reported greater self-efficacy in leadership behaviours when given the opportunity to observe, model and practice leadership behaviours.23 Ingersoll and colleagues34 found that when nurses reported more autonomy and control, their leaders used a facilitative leadership style whereas a structured leadership style was used with staff that required more direction. Young36 explored the types of educational opportunities available in the practice setting finding that individuals who ranked high on transformational leadership participated in more formal and informal leadership education.
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Educational activities (e.g. leadership development programs) were most frequently examined and the most significant factor contributing to increased leadership practices (nine studies).11,18–20,23,37–42 All nine studies using pre/post measures of leadership skills and competencies reported an increase in leadership skills and competencies when rated by either self or observers. Tourangeau and colleagues reported both significant development of leadership practices observed by others and no significant change in self-reported leadership practices after participation in a weekend leadership training course.20 Three studies measured the results of leadership development after one post-intervention measurement.23,38,40 Two of these three studies reported that increased leadership skills remained three months after participating in the leadership development program and the third study reported positive results both six and 12 months after the program.38
The leadership development programs varied widely in programming, length and delivery. They ranged in length of time from three days to 18 months, and from being offered in all-day workshop format, structured self-directed learning, to a five-day residency program with follow-up three months later. Three of the nine studies had very similar interventions focused on leadership development over a period of three or four days.11,40,42 Two studies extended their program with one four-day program being delivered over a period of two months and another program spanning 18 months with a variety of activities ranging from learning plans to observation.38 However, the specific contents of the leadership development programs were not reported in detail.
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Interventions to develop leadership
All studies that examined the influence of a leadership development program reported significantly increased leadership behaviours post intervention. However, given the propensity for published work to report positive results, these positive results should be viewed with cautious optimism. Our review may potentially be missing data about leadership development programs that did not significantly influence the development of leadership skills and were not published. With no control groups in these studies, the positive results stem primarily from observer or self-report methods without comparison to groups not receiving an intervention. Experimenter effects on self-report methods may also inflate the reporting of improvements. However, the use of observed measures of leaders' styles and behaviours by others strengthens the validity of these leadership study results. Leadership measures by followers are free of social desirability response bias often associated with leaders' self-report measures.43,44
Most of the leadership development programs in this review were conducted in workshop format with or without opportunities to receive coaching and mentoring from senior skilled leaders. The majority of studies based their interventions on pre-existing leadership development programs while two programs were developed in-house. Three studies reported that effects of training remained three months or longer. While the positive results were not differentiated across these different types of programs, leadership development programs could be structured in ways that are even more effective or particularly influential in developing specific leadership skills than those represented in the studies reviewed. Longitudinal research examining a variety of leadership development interventions, with data collection extending beyond 18 months and using both control and intervention groups, would help to determine the longer-term effects of educational interventions on leadership behavior.45 Such research would also identify whether the length or type of program influences the duration or magnitude of enhanced leadership behaviour.
The results of this review also point to the importance of leaders' role in modelling, demonstrating and practising leadership skills during the course of their work. As leaders develop and learn new skills, they should demonstrate, model and use these skills in the practice setting since study results suggest that leaders will continue to develop and improve by using their abilities as well as by teaching others. By wanting to learn and choosing to make an intentional behavioural change, people can change their performance on a complex set of competencies that distinguish outstanding managers.46 With the considerable financial resources that health care organizations invest in leadership development annually,47 the results of these studies suggest that investments in educational programs to develop leadership competencies are well placed.
Recruitment and selection of leaders
Studies examining traits and characteristics of nursing leaders found that higher levels of education and experience led to increased leadership effectiveness, with the exception of one study20 in which leaders with more experience were rated as exhibiting less effective leadership. These results suggest that the relationship between length of time in a leadership role and leadership practices can promote the development of leadership competence, as well as the development of burnout, job stress and apathy when leaders remain in their positions for lengthy periods.
Rozier31 found a balance between sex role characteristics, suggesting that an effective leader utilizes a blend of both masculine and feminine traits. The demographic results from the lone study on sex role indicated that leadership style tended to be high task and high relationship which also points to emotional intelligence, a theme consistent with studies from other leadership literature.2,48
Further research should explore the relationship between traits and characteristics, such as levels of education, experience, sex/gender roles and leadership in greater detail as the studies in this review provided no clear indication on how much education and expertise leads to greater leadership effectiveness. Additional research should also explore the sex role behaviour of male leaders in nursing to add diversity and contrast to the findings since nursing is a female dominated profession. This would provide additional insight into the characteristics and differences between female and male leaders in nursing.
Context and practice setting characteristics
Contact between the leader and staff is important as it provides opportunities for both staff nurses and leaders to use and develop their leadership skills. The reported reduction in leadership effectiveness resulting from increased distance between leader and staff may arise from leaders having fewer opportunities to use their leadership skills or staff not observing them.33 This suggests a need for health care organizations to understand the most effective way to use and implement leadership within the organization as visible and accessible leadership also increases job satisfaction and retention of staff.34
The influence of organizational climate in predicting leadership behaviour32 is consistent with the current interest in the relationship between context, culture and leadership.49 Leadership behaviours may also have a reciprocal relationship with organizational culture. The dynamic interplay between leadership and culture can be further explored as culture plays a strong role in many factors ranging from job satisfaction to staff retention. This knowledge could lead to more effective strategies on how health care organizations can support and implement leadership roles. Jones et al. suggested that behaviours involved in decision-making, information dissemination and developing interpersonal relationships within an organization can facilitate leadership development. Role taking in the transformational leadership perspective involves leader–follower exchange where the leader attempts to understand follower needs and the follower provides the leader with their perception of leadership effectiveness. This suggests that the process of role taking involves a relationship-based style of leadership and a need for leaders with high emotional intelligence. Employee maturity and situational leadership should also be explored further. Norris and Vecchio27 suggested that their non-significant results may arise from instrumentation, or employee maturity being rated as subjective and dynamic.
Last, the availability of educational opportunities including activities, ranging from formal lectures/in-services to informal staff mentorship in the practice setting, increased leadership behaviour. This suggests that providing opportunities to learn may strengthen leadership development.
There was a notable lack of random sampling in the reviewed studies due in part to the nature of studying leadership because the specific populations of leaders are most easily accessed by convenience sampling. However, to further strengthen study design, future research using probability sampling and quasi-experimental designs with matched or random allocation to control and intervention groups, is needed.47 The application of higher level multivariate statistical procedures like HLM and SEM can be used to test models and theories of leadership, specifically causal relationships of the influence of factors or interventions on the development of leadership. Models can include multiple factors contributing to nursing leadership and other variables influenced by leadership such as job satisfaction and retention. Finally, qualitative approaches examining the factors contributing to enhanced nursing leadership should be encouraged to generate themes and theoretical connections for future study.
One strength of this review was that the majority of studies were guided by a framework. Use of theoretical frameworks strengthen the validity of the study as theory provides a basis from which relationships between ideas and variables are constructed in order to be tested empirically, and to guide the choice of intervention design. However, we did not find a theoretical approach specific to leadership development in nursing, which is therefore an area for future development.
A variety of tools were used to measure leadership in this systematic review. The most frequently used were the Leadership Practices Inventory (three studies), Multifactor Leadership Questionnaire (two studies), Leader Behaviour Descriptive Questionnaire (three studies) and the Leadership Effectiveness and Adaptability Description (two studies). The remaining studies used other instruments including those developed by the study's researcher. While many studies had similar leadership goals, the researchers may have had different conceptualizations of leadership that encompassed a broad range of areas, styles and principles applied differently in a variety of settings. A variety of tools were used to measure leadership, therefore each may have measured a different conceptualization of leadership suggesting no consensus on the definition of leadership. Thus, leadership to nurses may vary from what leadership means to those in business or the military. The lack of reporting of leadership measurement tool validity (only 10 of 24 studies reported) limits the external validity of their findings. This is a topic that could be addressed by further qualitative inquiry to add greater depth to the conceptualization of leadership in nursing. Finally, only 11 of the 24 studies reported internal consistency greater than 0.70. While studies may have actually had appropriate validity and internal consistency, insufficient details may have been reported in the final study.
This review was limited by a potential reporting bias since published work tends to over report positive and significant findings. Variability in the conceptualizations and measurement of leadership may limit the validity and generalizability of the findings. No randomized control trials (RCTs) were found and there was limited control for extraneous variables. The exclusion of non-English studies may have resulted in overlooking additional evidence of specific culturally influenced factors that enhance or develop leadership in nursing. Finally, qualitative studies were not included due to the volume of quantitative studies selected which may reduce the comprehensiveness of results.
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| Acknowledgements |
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