The relationship between nursing leadership and patientoutcomes: a systematic review update

CAROL A. WONG PhD , RN1, GRETA G. CUMMINGS P hD , RN , F C AH S

2 and LISA DUCHARME BS c N , RN , MN3

1Associate Professor, Ontario Ministry of Health and Long-Term Care Nursing Early Career Research AwardRecipient, Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Health Sciences Addition (HSA),The University of Western Ontario, London, Ontario, 2Professor, Faculty of Nursing, Edmonton Clinic HealthAcademy, University of Alberta, Edmonton, Alberta and 3Practice Consultant, Nursing Professional ScholarlyPractice, London Health Sciences Centre (LHSC), London, Ontario, Canada

Correspondence

Carol A. Wong

Arthur Labatt Family School of

Nursing

Faculty of Health Sciences

Room H27, Health Sciences

Addition (HSA)

The University of Western

Ontario

1151 Richmond Street

London

Ontario N6A 5C1

Canada

E-mail: cwong2@uwo.ca

WONG C.A., CUMMINGS G.G. & DUCHARME L (2013) Journal of Nursing Management21, 709–724.The relationship between nursing leadership and patient outcomes: a

systematic review update

Aim Our aim was to describe the findings of a systematic review of studies that

examine the relationship between nursing leadership practices and patientoutcomes.

Background As healthcare faces an economic downturn, stressful work

environments, upcoming retirements of leaders and projected workforceshortages, implementing strategies to ensure effective leadership and optimal

patient outcomes are paramount. However, a gap still exists in what is known

about the association between nursing leadership and patient outcomes.Methods Published English-only research articles that examined leadership

practices of nurses in formal leadership positions and patient outcomes were

selected from eight online bibliographic databases. Quality assessments, dataextraction and analysis were completed on all included studies.

Results A total of 20 studies satisfied our inclusion criteria and were retained.

Current evidence suggests relationships between positive relational leadershipstyles and higher patient satisfaction and lower patient mortality, medication

errors, restraint use and hospital-acquired infections.Conclusions The findings document evidence of a positive relationship between

relational leadership and a variety of patient outcomes, although future testing of

leadership models that examine the mechanisms of influence on outcomes iswarranted.

Implications for nursing management Efforts by organisations and individuals to

develop transformational and relational leadership reinforces organisationalstrategies to improve patient outcomes.

Keywords: nursing leadership, patient outcomes, systematic review

Accepted for publication: 30 April 2013

Background

Considerable evidence has emerged in the past decade

linking nursing work environment characteristics, spe-

cifically nurse staffing, to patient outcomes, including

patient mortality and adverse events such as medica-

tion errors, hospital-acquired infections, pressure

ulcers and falls (Kovner & Gergen 1998, Aiken et al.

DOI: 10.1111/jonm.12116

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Journal of Nursing Management, 2013, 21, 709–724

2002, 2008, Needleman et al. 2002, Tourangeau et al.

2002, Cho et al. 2003, McGillis Hall et al. 2003,

Estabrooks et al. 2005, Blegen et al. 2011). However,

there is less research examining other work environ-

ment factors, specifically, nursing leadership and its

effects on patient outcomes.

Effective nurse leaders ensure that appropriate staff-

ing and other resources are in place to achieve safe

care and optimal patient outcomes. At the organisa-

tional level senior nurse executives contribute to stra-

tegic directions through their participation in senior

level decision-making and their ability to influence

how nursing is practised and valued (Huston 2008,

Wong et al. 2010). At the department and unit levels,

frontline leaders engage nurses in decision-making

about patient flow and staffing, quality improvement

activities, and continuous learning opportunities to

improve overall care delivery (Page 2004, Tregunno

et al. 2009, Thompson et al. 2011). The current eco-

nomic downturn, health and safety concerns associ-

ated with stressful work environments, more leaders

nearing retirement, and projected workforce shortages

are testing the abilities of healthcare leaders in sustain-

ing, let alone improving, the level of patient care. In

the challenge for organisations to make practices more

cost-effective yet improve outcomes, attract and retain

high-performing staff, and be more responsive to

patient needs, effective nursing leadership is critical to

advance agendas for change (Page 2004, Lowe 2005,

Fine et al. 2009).

The purpose of this study was to describe the find-

ings of a systematic review of studies in the literature

that examine the relationship between nursing leader-

ship practices and patient outcomes. In a previous

review, we searched electronic databases for the

20 years between 1985 and 30 April 2005 and found

only seven studies examining the relationship between

nursing leadership and patient outcomes (Wong &

Cummings 2007). In this review, we updated the evi-

dence by adding the results of studies published

between 1 May 2005 and 31 July 2012 to the evi-

dence reported in the previous paper and reviewed the

body of research on the relationship between nursing

leadership and patient outcomes.

Conceptual framework

A conceptual framework for the study review was

developed based on Donabedian’s (1966) structure–

process–outcome (SPO) framework (see Figure 1).

Three conceptual domains comprise this framework:

(1) structure which is concerned with organisational or

setting factors, (2) process which is concerned with

mechanisms for coordinating and facilitating patient

care and (3) outcomes of care. Originally described as

a framework for conceptualising the dimensions of

health care practice, Donabedian (1966) postulated

that each of these core dimensions was a necessary

condition for the one that followed. Structures influ-

ence processes and processes influence outcomes. The

SPO framework has been used extensively in examin-

ing relationships among organisational structural fea-

tures such as nurse staffing (Cho 2001, McGillis-Hall

& Doran 2007) or leadership (MacPhee et al. 2010)

and nurse (MacPhee et al. 2010) and patient outcomes

(Cho 2001, McGillis-Hall & Doran 2007). In this

review we describe the SPO framework to examine the

linkages between leadership and patient outcomes.

We isolated the leadership style of nurse leaders in

organisations 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’ (Shortell &

Kaluzny 2000, p. 109). We further categorised leader-

ship as either relational or task-oriented. Cummings

et al. (2010a) explained that leadership styles may be

broadly characterised as approaches that focus on peo-

ple and relationships (relationally oriented) to achieve

common goals or as styles that focus on structures and

tasks (task-oriented). Leaders differ in the extent to

which they pursue a human relations approach and

show concern and respect for followers, express appre-

ciation and support, and are genuinely concerned for

their welfare (Bass & Stogdill 1990). For example,

transformational leadership is a relational leadership

style in which followers have trust and respect for the

leader and are motivated to go above and beyond nor-

mal work expectations to achieve organisational goals

(Bass 1985, Bass & Avolio 1994).

Leaders also differ in their attention or focus on the

group’s goals and the means to achieve those goals

(Bass & Stogdill 1990). Those with a strong task ori-

entation define and organise the roles of followers, are

concerned with goals, procedures and production,

establish well-defined lines of communication, and are

likely to keep their distance psychologically from their

followers (Bass & Stogdill 1990). An example of a

task-oriented style is transactional leadership that

emphasises the transaction or economic exchange that

takes place among leaders, colleagues and followers to

accomplish work (Bass & Avolio 1994). The transac-

tional leader’s role is primarily that of recognising

follower needs and monitoring their role fulfilment

(Bass 1985, Bono & Judge 2004).

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The process concept in our framework was defined

as the leadership processes or mechanisms by which

leaders may contribute to patient outcomes. Examples

of these processes may include facilitating work condi-

tions 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 (Cummings et al.

2010a).

Outcome considers the measurable results of care

and we focused exclusively on patient outcomes.

Patient outcomes were defined as outcomes describing

patient mortality, patient safety outcomes such as the

incidence of adverse events involving patients (e.g.

falls, nosocomial infections) or complications during

hospitalisation, patient perceptions of satisfaction with

care, and healthcare utilisation such as length of stay

(Doran & Pringle 2011).

Methods

Inclusion criteria for studies

Following the same inclusion criteria used in the pre-

vious review, we included research studies that exam-

ined the relationship between nursing leadership in all

types of health care settings and one or more patient

outcomes. Leadership or aspects of leadership includ-

ing leadership styles, behaviours, competencies, or

practices were measured as self-reported by leaders,

direct observation of leaders or ratings of leader

behaviours made by followers. A leader was defined

as a nurse in a formal leadership role at any level in a

health care organisation (e.g. first line, middle and/or

senior leadership/management roles) and who super-

vises other nurses. Studies of clinical leadership in

staff nurses, evaluation of leadership development

programmes or the testing of leadership instruments

were excluded. We included only those studies that

examined the association between leadership and

patient outcomes reported as direct observation of

patient outcomes or extracted from administrative

databases. Studies of nurse- or staff-reported patient

outcomes were excluded. There was no restriction on

study design and published English-only articles were

reviewed. We also required that the relationship

between leadership and patient outcomes(s) be

expressed quantitatively and tested statistically.

Search strategy and data sources

We searched the following eight online bibliographic

databases for the period 1 May 2005 to 31 July 2012:

ABI Inform Dateline, Academic Search Complete,

Cochrane Database of Systematic Reviews (CDSR),

MEDLINE, CINAHL, EMBASE, ERIC and PsychI-

NFO. Table 1 includes a summary of the search strat-

egy. Some of the databases have changed since the

previous review, however, we were careful to include

all the same sources as in the last review. We also

hand searched the journals, Journal of Nursing Man-

agement, Nursing Research, Nursing Leadership, The

Leadership Quarterly, Journal of Nursing Administra-

tion and Journal of Organizational Behavior as well

as the bibliographies of articles identified for inclusion

in the review. As in the last review we searched

research websites for relevant research reports.

Study identification and quality review

The primary author and a research assistant screened

the titles and abstracts of the articles identified by the

search strategy. Articles that potentially met our inclu-

sion criteria, and where there was insufficient informa-

tion to make a decision regarding inclusion, were

retrieved and assessed for relevance by the primary

author and a research assistant. To assess the method-

ological quality of the final set of articles, we used the

Figure 1

Framework for systematic review

(Donabedian 1966).

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Systematic review update

same quality assessment tool which was adapted and

used in the initial review (Wong & Cummings 2007)

and also used in several published systematic reviews

(Cummings & Estabrooks 2003, Estabrooks et al.

2003, Lee & Cummings 2008). Each study was

reviewed for quality twice by the lead author. The

adapted tool was used to assess the research design,

sampling, measurement and statistical analysis of each

study. Thirteen criteria comprise the tool and a total

of 14 possible points can be assigned for all 13 criteria

(Table 2). 12 items were scored as 0 = not met or

1 = met and the item related to outcome measurement

was scored as 2. Based on summed point values, stud-

ies were then classified as: weak (0–4), moderate (5–9)

and strong (10–14).

Data extraction and analysis

The lead author extracted data from all included arti-

cles that were double-checked by a research assistant

for accuracy. Data were extracted on the study

author, journal, country, research purpose and ques-

tions, theoretical framework, design, setting, subjects,

sampling method, measurement instruments, reliability

and validity, analysis, leadership measures, measures

Table 2

Summary of quality assessment – 20 included quantitative papers

(includes: seven studies from previous review)

Criteria

No. of studies

Yes No

Design

Prospective studies 20 0

Used probability sampling 5 15

Sample

Appropriate/justified sample size 6 14

Sample drawn from more than one site 15 5

Anonymity protected 19 1

Response rate >60% 8 12

Measurement

Reliable measure of leadership 20 0

Valid measure of leadership 19 1

Effects (outcomes) were observed

rather than self-reported*14 6

Internal consistency ≥ 0.70 when

scale used

13 7

Theoretical model/framework used 13 7

Statistical analyses

Correlations analysed when multiple

effects studied

18 2

Management of outliers addressed 5 15

Weak (0–4), moderate (5–9), strong (10–14), moderate (n = 3),

strong (n = 17).

*This item scored 2 points. All others scored 1 point.

Table 1

Literature search: electronic databases

Database Search terms

Number of articles

May 2005 to July 2012

Main Search Terms/Concepts

Nurse AND Leadership AND Patient Outcome

OR Quality of Healthcare AND Research

ABI Inform Dateline all(nurse*) AND all(leader*) AND all(patient outcomes) 59

Academic Search Complete (MM leadership OR TI leader*) AND (TI outcome*OR MM ‘Outcomes (Health Care)’

OR MM ‘Nursing outcomes’) AND TX nurs*

2892

CINAHL (MM leadership OR TI leader*) AND(TI outcome* OR MM ‘Outcomes (Health Care)’

OR MM ‘Nursing outcomes’) AND TX nurs*

4592

Cochrane ‘nurse* AND Administr* OR manag*OR leader* AND patient satisfaction

OR patient safety OR patient outcome*OR outcome* OR safety OR infection*OR fall* OR medication error* OR incident report*

643

EMBASE Leadership (MESH) AND nurs*tiab) AND Quality of Healthcare (MESH) AND research (tiab)

3444

ERIC ‘leadership’ AND ‘quality of health care’ OR ‘outcomes of treatment’ 214

MEDLINE Leadership (MESH) AND nurs* (tiab) AND

Quality of Healthcare (MESH) AND research (tiab)

6627

PsychINFO Leadership (MESH) AND nurs* (tiab) AND

Quality of Care (MESH) AND research (tiab)

1902

Manual Search 10

Total 20 383

Total Minus Duplicates 15 180

Papers reviewed 121

Final Selection 13

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C. A. Wong et al.

of effects on patients, significant and non-significant

results, discussion and recommendations. Appendix S1

includes data extraction for the 13 studies retained in

this updated review along with the data from the

seven studies identified in the previous review.

Using content analysis and the conceptual frame-

work as a guide, leadership was categorised as rela-

tionship or task-oriented and patient outcomes were

sorted into thematic categories based on their com-

mon characteristics and our previously defined out-

come categories (Doran & Pringle 2011). Second,

within each thematic category we identified the pat-

tern of relationships between relational or task

focused styles of leadership and changes in specific

patient outcomes. For example, we looked at which

leadership styles were predominantly associated with

specific outcomes such as patient satisfaction and if

patient satisfaction increased or decreased as a result

of leadership style. We then analysed the reported

relationships between the specific leadership styles or

practices and the outcomes by category and signifi-

cance (P < 0.05). We also reviewed studies for the

processes by which leadership influenced outcomes

that were either tested or discussed in studies and or-

ganised into themes based on common characteristics.

Results

Description of studies

Article selection for this review is summarised in

Figure 2. Database and hand searches yielded 20 383

titles/abstracts and of these, 121 were identified as

potentially relevant after title and abstract review.

One of the 121 studies was a published journal article

(McCutcheon et al. 2009) of one of the retained seven

studies in our previous review (Doran et al. 2004)

which we obtained as a research report from a

research website. We excluded that article plus 107

others, leaving only 13 studies meeting our selection

criteria after article reviews.

We added these 13 articles to the seven articles

retained in our previously reported systematic review

(Wong & Cummings 2007) and described the charac-

teristics of all 20 included studies. These articles repre-

sent 20 original studies with the exception of the

Capuano et al. (2005) paper which built on the Houser

(2003) study by using the same conceptual model, col-

lecting data on the same variables in another setting

and then adding the data to the Houser (2003) database

and re-tested the model. All 20 studies were published

between 1999 and July 2012 and all but five were

conducted in the United States, the others being con-

ducted in Canada (n = 4) and Norway (n = 1). The

studies represented a variety of care settings: inpatient

acute care units of hospitals (n = 12), nursing homes

(n = 4), dialysis facilities (n = 1), emergency units

(n = 1), home healthcare agencies (n = 1) and neonatal

intensive care (n = 1). The findings were combined

despite the variety of settings. The study samples repre-

sented nurses (n = 10), nurses and managers (n = 6), a

cross-section of healthcare professionals including

nurses (n = 2), a combination of nurses, auxiliary

nurses and unlicensed care staff (n = 1) and directors of

nursing (n = 1). Further details on the characteristics of

all 20 included studies can be found in Appendix S1.

Methodological quality of included studies

The methodological quality of the included articles is

summarised in Table 2. All articles used a cross-sec-

tional design and of the 20 included articles,

17 (85%) were rated as strong and 3 (15%) as moder-

ate. Strengths of the studies included the fact that the

majority (n = 19, 95%) used reliable and valid mea-

sures, were multi-sited studies (n = 15, 75%), had

acceptable sample sizes (n = 17, 85%) and reported

correlations of multiple effects (n = 18, 90%). In all

but one study, leadership was measured by asking

followers to rate the leadership style of their formal

leader. Observed leadership behaviours assessed by a

leader’s followers contributes to the construct validity

of the measurement of leadership more effectively

than leader self-report (Dunham 2000, Xin & Pelled

2003), because self-report measures are subject to

social desirability response bias (Polit & Beck 2011).

Six (30%) studies used only self-report measures for

patient outcomes, specifically satisfaction with care.

All other patient outcome measures were collected

prospectively in the study or extracted from adminis-

trative databases. Eighteen (90%) studies reported

using multivariate analysis including multiple regres-

sion, logistic regression, hierarchical linear modelling

(HLM), or structural equation modelling (SEM). The

unit of analysis for leadership and patient outcomes

was the unit/organisational level in 17 studies.

Weaknesses of studies identified in the quality

assessment related mainly to sample representative-

ness, treatment of outliers, explicit inclusion of a con-

ceptual or theoretical framework, response rates and

reporting study reliabilities for measures used. Only

five (10%) of studies reported using random sampling

and 12 (60%) had response rates less than 60%. Six

(60%) addressed outliers in their data, while seven

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Table 3

Summary of study outcomes: relationship between leadership and patient outcomes

Patient outcomes Source Significant findings

Comment – relational (=R) ortask-oriented leadership (=T)

Patient satisfaction Doran et al. (2004) Increased Transactional leadership style (R)

Larrabee et al. (2004) NS Transformational leadership (R)

McNeese-Smith (1999) Increased Transformational leadership practices (R)

Gardner et al. (2007) NS Manager ability and support (R)

Kroposki & Alexander (2006) Increased Supervisors work collaboratively with staff (R)

Raup (2008) NS Transformational leadership (R)

Havig et al. (2011) Increased Task-oriented leadership (T)

Patient mortality Houser (2003) Decreased Transformational leadership practices through

increased staff expertise and stability (R)

Pollack and Koch (2003) NS Higher leadership (only respiratory therapists’

ratings were significant (R) &(T)

Boyle (2004) NS Inverse association with manager ability

and support (R)

Capuano et al. (2005) Decreased Transformational leadership practices

through increased staff expertise (R)

Cummings et al. (2010b) Decreased High resonant leadership (R)

Tourangeau et al. (2007) Increased Manager ability and support (R)

Patient safety:

(a) Adverse events

Behaviour problems Anderson et al. (2003) Decreased Participative leadership (R)

Restraint use Anderson et al. (2003) Decreased Communication openness (R)

Castle & Decker (2011) Decreased Consensus leadership (R)

Complications of

immobility

Anderson et al. (2003) Decreased Relationship-oriented leadership and less

formalisation (R)

Fractures Anderson et al. (2003) Decreased Relationship-oriented leadership (R)

Medication errors Houser (2003) Decreased Transformational leadership practices

through increased staff expertise and

stability (R)

Boyle (2004) NS Manager ability and support (R)

Capuano et al. (2005) Decreased Transformational leadership practices

through increased staff expertise (R)

Paquet et al. (2013) Decreased Unit manager support through reduced

absenteeism, overtime and nurse–patient

ratio (R)

Vogus & Sutcliffe (2007b) Decreased Trust in leadership increased the effect of

safety organising behaviours (R)

Patient falls Houser (2003) Decreased Transformational leadership practices

through greater staff expertise and

stability (R)

Boyle (2004) NS Manager support ability and support

Capuano et al. (2005) Decreased Transformational leadership practices

through greater staff expertise (R)

Taylor et al. (2012) NS Positive perceptions of hospital

management (R)

Catheter use Castle and Decker (2011) Decreased Consensus leadership (R)

Pressure ulcers Boyle (2004) NS Inverse association with manager ability

and support (R)

Castle and Decker (2011) Decreased Consensus leadership (R)

Flynn et al. (2010) NS Inverse association with manager ability

and support (R)

Taylor et al. (2012) NS Positive perceptions of hospital

management (R)

Inadequate pain

management

Castle and Decker (2011) Decreased Consensus leadership (R)

Hospital infections

(pneumonia and UTI)

Houser (2003) Decreased Transformational leadership practices

through greater staff expertise (R)

Boyle (2004) NS Nurse manager ability and support (R)

Capuano et al. (2005) Decreased Transformational leadership practices

through greater staff expertise (R)

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(35%) failed to include explicit theoretical or concep-

tual frameworks to guide the research and seven

(35%) failed to achieve or report acceptable

(a > 0.70) alpha reliabilities of the measures used in

their studies.

Leadership

Leadership was measured in these studies as leadership

styles, behaviours, competencies and practices. The lead-

ership concepts or themes across studies were transfor-

mational/transactional leadership (McNeese-Smith

1999, Houser 2003, Doran et al. 2004, Larrabee et al.

2004, Capuano et al. 2005, Raup 2008), relational, par-

ticipative or consensus leadership practices (Anderson

et al. 2003, Kroposki & Alexander 2006, Castle &

Decker 2011), task- or relationship-oriented leadership

(Havig et al. 2011), resonant leadership (Cummings

et al. 2010b), leader ability and support (Pollack &

Koch 2003, Boyle 2004, Gardner et al. 2007, Touran-

geau et al. 2007, Flynn et al. 2010, Hansen et al. 2011,

Paquet et al. 2013), trust in leadership (Vogus & Sutc-

liffe 2007b) and positive perceptions of leaders (Taylor

et al. 2012).

In nine studies (45%), an explicit leadership theory

was used as the basis for the leadership variable. Bass

and Avolio’s (1994) transformational leadership

theory was used in three studies (Doran et al. 2004,

Larrabee et al. 2004, Raup 2008) and Kouzes and

Posner’s (1995) transformational leadership practices

model was used in another three studies (McNeese-

Smith 1999, Houser 2003, Capuano et al. 2005). Gol-

eman et al.’s (2002) resonant leadership (Cummings

et al. 2010b), the Bonoma-Slevin leadership model

(Castle & Decker 2011) and Bass and Stogdill’s

(1990) conceptualisation of task vs.-relations-oriented

leadership (Havig et al. 2011) were each used in one

of three studies. Thirteen different tools were used to

measure leadership and the most frequently used tools

were Bass and Avolio’s (1995, 2000) Multifactor

Leadership Questionnaire (MLQ) (n = 3 studies), and

Kouzes and Posner’s (1995) Leadership Practices

Inventory (LPI) (n = 3 studies). In two studies mea-

sures of leadership were developed for the study: one

used items of other standardised measures to assess

task-and relationship-oriented leadership (Havig et al.

2011) and the other developed items to measure trust

in leadership (Vogus & Sutcliffe 2007b).

Leadership was measured using a component or

subscale of multi-dimensional measures of the work

context in seven studies. In fact this trend was evident

in six of the 13 retained studies in the more recent

search. The most commonly used (n = 4 studies) mea-

sure was the manager ability and support subscale of

Aiken and Patrician’s (2000) Nursing Work Index-

Revised (NWI-R) (Boyle 2004, Gardner et al. 2007,

Tourangeau et al. 2007, Flynn et al. 2010) while in

four studies manager support subscales of Singer

et al.’s (2009) Patient Safety Climate in Healthcare

Organizations (PSCHO) survey (Hansen et al. 2011),

Sexton et al.’s (2000) Safety Attitudes Questionnaire

(SAQ) (Taylor et al. 2012), Karasek et al.’s (1998)

Table 3

Continued

Patient outcomes Source Significant findings

Comment – relational (=R) ortask-oriented leadership (=T)

(b) Complications

Neonatal PIVH/PVL

Retinopathy of prematurity(ROP)

Pollack & Koch (2003) Decreased Higher leadership (combined ratings of

RNs, MDs & RTs) (R) & (T)

Pollack & Koch (2003) Decreased Only MDs composite leadership scores

(R) & (T)

Pulmonary embolism/

deep vein thrombosis

Taylor et al. (2012) NS Positive perceptions of hospital

management (R)

Patient healthcare utilisation

Number of

hospitalizations for

dialysis patients

Gardner et al. (2007) NS Manager ability and support (R)

Hospital readmission

rates (AMI, HF or

pneumonia)

Hansen et al. (2011) NS Manager support (R)

Length of hospital stay Paquet et al. (2013) Decreased Manager support through reduced

absenteeism, overtime and nurse–patient

ratio (R)

NS, not significant.

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Job Content Questionnaire (Paquet et al. 2013) and

Shortell et al.’s (1991) Organisational Assessment

Scale (Pollack & Koch 2003) were used to assess

leadership.

Process

As outlined in our conceptual framework, leadership

influences patient outcomes indirectly through pro-

cesses such as making changes in the work context or

influencing staff attitudes, behaviour or performance

that may facilitate patient care. In three of the reviewed

studies, the mechanisms or processes by which leader-

ship was indirectly related to patient outcomes were

explicitly tested using structural equation modelling

(Houser 2003, Capuano et al. 2005, Paquet et al.

2013). Houser (2003) found that transformational

leadership practices were positively related to staff

expertise and negatively related to staff turnover, both

of which contributed to reduced patient mortality, hos-

pital acquired infections, medication errors and patient

falls. Capuano et al. (2005) added to these findings by

showing that transformational leadership practices

were also associated with staff expertise, which in turn

decreased the same adverse patient outcomes. Both

authors postulated that strong leaders tend to retain

higher ratios of competent and proficient staff. Paquet

et al. (2013) findings also revealed the indirect effect of

leadership on patient outcomes (decreased medication

errors and patient length of stay) through reduced

absenteeism, overtime and nurse/patient ratios. In one

study relational leadership (trust) was examined as a

moderator variable, which increased the strength of the

negative relationship between staff safety organising

behaviour and the incidence of medication errors (Vo-

gus & Sutcliffe 2007b).

In the other studies, leadership was examined in

direct association with outcomes and the authors dis-

cussed possible mechanisms by which leadership

styles may have affected outcomes. Cummings et al.

(2010b) pointed to the positive effect on staff perfor-

mance outcomes when leaders present a clear leader-

ship style, convey unambiguous expectations and

engage in open and transparent communication prac-

tices. Other studies suggested that positive leadership

behaviours may be associated with outcomes through

facilitation of more effective teamwork or a clear

vision for quality care (McNeese-Smith 1999, Ander-

son et al. 2003, Pollack & Koch 2003, Doran et al.

2004). Relational leadership styles may also facilitate

higher levels of staff participation in care decision-

making (Boyle 2004, Kroposki & Alexander 2006,

Cummings et al. 2010b, Castle & Decker 2011).

Finally, the current focus on patient safety in health-

care organisations was evident in three studies that

identified the effect of work climate factors including

leadership on safety awareness and organising pro-

cesses as possible mediators of patient safety out-

comes (Vogus & Sutcliffe 2007b, Hansen et al.

2011, Taylor et al. 2012).

Relationship between leadership and patientoutcomes

In this review we found 19 patient outcome variables

which were grouped into five categories using

content analysis: relationship between leadership and

(1) patient satisfaction, (2) patient mortality, patient

safety outcomes, (3) adverse events and (4) complica-

tions, and (5) patient healthcare utilisation. A sum-

mary of findings is presented in Table 3. In 30%

(n = 6) of studies patient outcomes, primarily patient

or family satisfaction, were collected prospectively by

researchers. In one study (Pollack & Koch 2003)

patient mortality and complications were collected

from clinical charts and in all other studies patient

Figure 2

Selection of articles for review.

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C. A. Wong et al.

outcomes were collected from administrative databas-

es. Of the individual outcomes, patient mortality

(n = 6 studies) and medication errors (n = 5 studies)

were the most frequently examined outcomes. Over

all studies, a total of 43 relationships between leader-

ship and patient outcomes were examined and 63%

(n = 27) of these were significant. While 26 relation-

ships between leadership and positive patient out-

comes were significant, one relationship showed the

opposite of the expected results.

Patient satisfaction

The number of studies (n = 7) relating leadership

practices to patient satisfaction was more than dou-

bled in this review. The results showed significant

associations between leadership and increased patient

satisfaction in four studies (McNeese-Smith 1999,

Doran et al. 2004, Kroposki & Alexander 2006,

Havig et al. 2011). In three others (Larrabee et al.

2004, Gardner et al. 2007, Raup 2008) the results

were not significant. One of these studies had a small

sample and had the lowest quality rating (Raup

2008). Relational leadership was associated with

patient satisfaction in two studies (McNeese-Smith

1999, Kroposki & Alexander 2006) while Havig et al.

(2011) found that family satisfaction with resident

care was significantly positively related to task-

oriented leadership style of nursing home ward man-

agers. Similarly, Doran et al. (2004) found that the

transactional leadership style, which can also be cate-

gorised as task-oriented, was related to increased

patient satisfaction. Doran et al. offered the explana-

tion that transactional leaders may facilitate patient

care by providing direction, clarification of tasks and

clear work expectations.

Patient mortality

In four of six studies leadership was significantly asso-

ciated with patient mortality (Houser 2003, Capuano

et al. 2005, Tourangeau et al. 2007, Cummings et al.

2010b). 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 (Touran-

geau et al. 2007). Tourangeau et al. 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 contradic-

tory 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 out-

comes in this category. The strongest relationship was

between leadership and medication errors, as four of

five studies showed significant negative relationships.

Transformational leadership (Houser 2003, Capuano

et al. 2005), manager support (Paquet et al. 2013)

and trust in leadership (Vogus & Sutcliffe 2007b)

were all associated with lower medication errors.

Patient falls were examined in four studies and the

results were mixed since two studies (Houser 2003,

Capuano et al. 2005) showed significantly decreased

patient falls related to transformational leadership,

while in two other studies (Boyle 2004, Taylor et al.

2012) 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 (Castle & Decker 2011). Two studies

(Anderson et al. 2003, Castle & Decker 2011) found

significant relationships between positive leadership

Figure 3

Structure-Process–Outcome relation-

ships suggested by review findings.

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Journal of Nursing Management, 2013, 21, 709–724 717

Systematic review update

styles (consensus and participative) and lower restraint

use in nursing homes. In two of three studies examin-

ing hospital-acquired infections (pneumonia and uri-

nary tract infections) transformational leadership was

associated with lower infection rates (Houser 2003,

Capuano et al. 2005).

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. Pollack and Koch’s

(2003) study conducted in neonatal intensive care

settings found a reduced incidence of neonatal peri-

ventricular haemorrhage/periventricular leukomalacia

(PIVH/PVL) associated with higher leadership rat-

ings. Taylor et al. (2012) found no relationship

between leadership and pulmonary embolism/deep

vein thrombosis.

Patient healthcare utilisation

A new category of patient outcomes was added since

three studies addressed patient healthcare utilisation

indicators, specifically the number of hospitalisations,

hospital readmissions and hospital length of stay as out-

comes related to work environment factors including

leadership (Gardner et al. 2007, Hansen et al. 2011,

Paquet et al. 2013). Healthcare utilisation measures

reflect services or resources consumed in managing

patients’ health-related needs (Clarke 2011). Gardner

et al. (2007) proposed that patient hospitalisations are

considered important indicators of the general health

status of patients who are on dialysis and may be con-

sidered a reasonable nurse-sensitive quality indicator in

dialysis settings. Hansen et al. (2011) 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. Man-

ager support was included as one element of patient

safety culture. Both studies did not demonstrate signifi-

cant findings for the effects of leadership on these two

healthcare utilisation outcomes. However, Paquet et al.

(2013) 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.

Discussion

In this systematic review we examined empirical evi-

dence on the connections between nursing leadership

and patient outcomes by extending the search criteria of

the previous review to include studies published

between 1985 and 30 July 2012. The 13 additional

studies published after our first systematic review

almost triples the number of studies specifically examin-

ing the relationship between nursing leadership and a

variety of patient outcomes. The totality of the 20

included studies reflects positive trends in terms of

research design and methods. Most studies were multi-

sited, incorporated multiple levels of analysis, used

more advanced statistical procedures (e.g. HLM, SEM)

and examined the relationship leadership and patient

outcomes in a wider variety of clinical settings, although

the majority were conducted in acute care. What was

disappointing was that less than half of the studies used

explicit leadership models, very few studies examined

mechanisms of leadership influence on outcomes, there

was an over-reliance on cross-sectional designs and con-

siderable heterogeneity of patient outcomes and clinical

settings precluding greater synthesis of findings.

The findings provide support for the assertion that

relational leadership practices are positively associated

with some categories of patient outcomes. The Donabe-

dian (1966) SPO model provided a useful approach to

organising findings which are summarised in a diagram

depicting suggested linkages between relational or task

oriented leadership, processes of leadership and three of

the patient outcomes where findings were supported in

terms of number of studies and direction of effect (Fig-

ure 3). The findings 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. There were also promising trends in find-

ings for restraint use and hospital-acquired infections.

Findings on mortality outcomes were strong showing a

significant negative relationship between leadership and

patient mortality in three of six studies. This important

connection may suggest that effective nursing leader-

ship is essential to the creation of practice environ-

ments, with appropriate staffing levels, resources and

care processes that support nurses in preventing unnec-

essary deaths (Wong & Cummings 2007). Finally, there

was a significant positive relationship between both

relational and task-oriented leadership and patient sat-

isfaction. 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.

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C. A. Wong et al.

Implications for leadership theory

Despite progress in acknowledging the inclusion of

leadership as an important factor in theoretical and

analytical models of antecedents to patient outcomes,

there is a pressing need for much stronger conceptuali-

sations of leadership that clearly define leadership

practices and specify possible direct and indirect

mechanisms by which leaders affect individuals and

outcomes (Avolio 2007, Gilmartin & D’Aunno 2007).

Although some of the studies included multi-level

analyses of individual-, unit- and organisational-level

variables, the articulation of mechanisms by which

leadership influences the various levels was often inad-

equate. While an important concept, the definition

and measurement of leadership as manager ability or

support is a somewhat narrow notion of leadership, as

opposed to more complex explanations of leadership

behaviour and influence strategies suggested in other

theories such as transformational or resonant leader-

ship theory.

Transformational leadership was the most fre-

quently 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 mediat-

ing processes they propose between leadership and

outcomes (Mark et al. 2004, Gilmartin & D’Aunno

2007). For example, authentic leadership (Avolio

et al. 2004) is an emergent leadership approach from

the field of positive organisational behaviour 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 capaci-

ties, honesty and transparency, strong ethics and

behavioural integrity (Avolio et al. 2004, Wong &

Cummings 2009). The utility of this theory is that it

emphasises possible mechanisms through which lead-

ership influences performance, and how followers

shape leadership within and between various organisa-

tional contexts, climates and cultures (Peterson et al.

2012). Testing of various propositions about mecha-

nisms of leader influence on individual, unit and

organisational outcomes suggested by the theory

might include the effects of leader positivity on

followers’ engagement and performance in new work-

place initiatives that promote patient safety and better

outcomes.

Resonant leadership theory (Boyatzis & McKee

2005) based on the concept of emotional intelligence

(Goleman et al. 2002) is also worthy of greater appli-

cation in healthcare. These theories focus on the lea-

der’s ability to attend to the individual’s emotions and

the outcomes of these behaviours for individual’s well-

being and performance (Cummings 2004). 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, pro-

cesses and patient outcomes (Graen & Uhl-Bien

1995). 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.

Research has linked LMX quality to positive individ-

ual and organisational outcomes, including job perfor-

mance (Laschinger et al. 2007).

Implications for future research

Future studies need to include longitudinal, quasi-

experimental or experimental designs that address the

effects of leadership on patient outcomes. In order to

examine the causal association between leadership and

patient outcomes, interventional and/or longitudinal

studies with multiple observations are essential. It is

concerning that even though there was a substantial

increase in the number of studies addressing leadership

and patient outcomes all of the studies were cross-

sectional in design. The trend seen in this review for

studies examining leadership and patient outcomes in

other than acute care settings, e.g. nursing home, home

healthcare and community settings needs to be contin-

ued. The majority of studies were multi-sited which is

important for obtaining adequate sample sizes for

multi-level analysis. However, these studies also present

a significant challenge in terms of collecting reliable

and valid data from multiple sites. Likewise, the use of

random sampling procedures would significantly

strengthen studies. In this review the majority of studies

used convenience sampling. One notable issue was that

only eight (40%) of studies had a response rate of 60%

or more, despite convenience sampling. Additional

activities to increase response rates would improve the

reliability of the results and strengthen data analysis,

although the challenge of accessing subjects in increas-

ingly complex, dynamic and fast-paced healthcare set-

tings must be acknowledged.

Implications for practice

The findings from this review underscore the value of

relational leadership styles in the modern healthcare

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Journal of Nursing Management, 2013, 21, 709–724 719

Systematic review update

workplace and align with findings from other reviews

where relational leadership styles were positively and

indirectly related to nurse’s motivation to perform

(Brady-Germain & Cummings 2010), improved work

environments and outcomes for nurses (Cummings

et al. 2010a) and nurse retention (Cowden et al.

2011). These findings suggest that a complex interplay

of associations between the relational practices of for-

mal nursing leaders to provide vision, support, staffing

resources (Kane et al. 2007) and leadership, with the

health, competencies, abilities, knowledge, skills and

motivation of nurses, are integral to the achievement

of better patient outcomes.

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 lev-

els of organisations (Cummings 2004, Young-Ritchie

et al. 2009). Relationally oriented leaders contribute

to positive practice settings and staff work engage-

ment by providing support and encouragement, posi-

tive and constructive feedback, open and transparent

communication and individual consideration. Creat-

ing 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.

Thompson et al.’s (2011) recent study provided evi-

dence that when leaders demonstrated higher rela-

tional 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 recognise and

implement effective safety practices (Tregunno et al.

2009, Thompson et al. 2011). Additionally, the

development of safety cultures through leadership

interventions, which include managers’ interdisciplin-

ary walkabout safety rounds, have been linked to

improved outcomes (Ginsburg et al. 2005).

Limitations

Even though meticulous methods were employed in

this review there were limitations. First, the variety

of leadership and outcome measures and the hetero-

geneity of samples and settings precluded meta-analy-

sis procedures and limited the consolidation of

findings. While an attempt was made to review some

grey literature (e.g. searching research websites) we

did not search all grey literature and did not include

unpublished dissertations, and, as such, this review

update may not be representative of all the relevant

work in the field. The inclusion of studies published

only in the English language may have also excluded

other potentially informative studies. Studies may

have been excluded that contained leadership data

but because it was not purposely hypothesised or dif-

ferences in outcomes by leadership style were not

examined those results were not accessible. The vari-

ability in the conceptualisation and measurement of

leadership across studies may limit the validity and

generalisability of findings. All of the studies included

were cross-sectional in design, limiting interpretations

of causality to the evidence of co-variation in the

study variables and foundational theoretical associa-

tions. The theoretical underpinnings and causal

understandings of studies were not reported by all

researchers, which may have influenced appropriate

synthesis of findings.

Conclusion

In this systematic review update we identified an

increasing body of research findings relating to the

relationship between nursing leadership and patient

outcomes. However, the prominence of cross-sectional

designs and the heterogeneity in patient outcome vari-

ables, samples/settings and leadership measures mean

that robust evidence to support specific leadership

styles that predict specific patient outcomes is limited.

The current evidence reinforced findings from the pre-

vious 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 rela-

tionship between relational leadership styles and lower

patient mortality and reduced medication errors,

restraint use, and hospital-acquired infections. Future

studies of a longitudinal and interventional nature

must be conducted in a variety of settings with more

diverse and randomly selected samples. In addition, the

development and testing of stronger conceptual models

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720 Journal of Nursing Management, 2013, 21, 709–724

C. A. Wong et al.

of leadership and the mechanisms of influence on patient

outcomes is warranted to advance knowledge of the

complex contextual and multivariate influences on the

relationship between leadership and patient outcomes.

Sources of funding

We gratefully acknowledge salary funding support

through the Ontario Ministry of Health and Long-

Term Care Nursing Early Career Research Award and

in-kind support from the University of Western

Ontario.

Ethical approval

Ethical approval was not required for this paper.

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Supporting information

Additional Supporting Information may be found in

the online version of this article:

Appendix S1. Characteristics of included studies.

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