The association between nurse managers' transformational leadership and quality of patient care: A systematic review

The Journey to First-Line Nursing Management: A Qualitative Study in a Spanish University Hospital

AIM

To explore nurse managers' perceptions at first-line, middle and executive levels regarding their transition to first-line management in two divisions of a highly specialised university hospital in Spain.

DESIGN

A qualitative descriptive study.

METHOD

A purposive sampling technique was employed to conduct four focus groups and two semi-structured interviews with 31 nurse managers across three hierarchical levels in two divisions of a highly specialised university hospital in Spain. Participants included two Chief Nursing Officers, four Nursing Directors and 25 first-line nurse managers. Data were analysed thematically.

RESULTS

Three themes emerged: 'Bridging the Readiness Gap: Training, Role Clarity, and Institutional Alignment', revealing the lack of structured transition plans, role ambiguity and gaps in managerial skills, such as human resources, financial management and leadership; 'Fighting Loneliness: A Common Challenge in Care Management', highlighting the isolation of first-line nurse managers due to the absence of structured mentorship and peer support; 'Clinical Expertise as a Cornerstone: The Role of Prior Experience in Nurse Management', examining how clinical expertise facilitates leadership transitions but also presents challenges, particularly for managers promoted within their teams, where authority negotiation and role redefinition become critical.

CONCLUSIONS

Findings underscore the need for structured training and mentorship to address role ambiguity, enhance managerial competencies and support nurse managers' transitions through targeted education.

IMPLICATIONS FOR PROFESSION AND PATIENT CARE

Structured transition programmes focusing on role clarity, training and institutional alignment can ease transitions, boost leadership confidence and enhance peer collaboration. Providing mentoring and training tailored to first-line nurse managers can improve team dynamics, support professional integration and strengthen organisational cohesion.

IMPACT

Tailored educational interventions are essential in supporting nurse managers' transitions. Structured mentorship and targeted training enhance leadership readiness, adaptability and institutional alignment, strengthening healthcare leadership, efficiency and patient care quality.

PATIENT AND PUBLIC CONTRIBUTION

No patient or public contribution.

Using Behaviour Diagnostics to Identify Enablers and Barriers to Optimise Nurse and Midwife Manager Leadership Time

Background: Effective nursing and midwifery leadership benefits patients, staff and organisations. In February 2024, all nurse/midwife managers (N = 89) across one organisation transitioned to five allocated leadership days per week. For many nurse/midwife managers, whose default was to assume the clinical shift leader role when the unit was busy or short staffed, optimising use of five allocated leadership days per week required significant behaviour change. Aim: The aims of this study were to: (i) examine the enablers and barriers to nurse/midwife managers using allocated leadership time to fulfil their core responsibilities and (ii) develop a theory-informed implementation plan to optimise allocated leadership time use. Methods: A survey of all nurse/midwife managers, underpinned by the Theoretical Domains Framework, enabled identification of enablers and barriers to using allocated leadership time. The Behaviour Change Wheel was used to map enablers and barriers, identify intervention functions and behaviour change techniques to form an implementation plan. The APEASE criteria (acceptability, practicability, effectiveness, affordability, side effects/safety and equity) were applied to ensure effective and feasible strategies were selected. Results: The response rate was 62.5% (55/89). Reflective motivation was the dominant enabler (clear goals, intentions and optimism). The most common barriers were reflective motivation (feeling responsible if an adverse event impacted staff or patients; perceptions of lack of control); automatic motivation (feelings of guilt, anxiety and stress if using allocated leadership time when their area is short staffed) and social opportunity (social influences and balancing the expectations of others). A range of intervention functions were necessary to support identified enablers and address identified barriers to nurse/midwife managers optimising their use of allocated leadership time. Conclusions: Behaviour change theory is useful for identifying real-world enablers and barriers of nurse/midwife managers' use of allocated leadership time and developing a theory-informed implementation plan to optimise use of their allocated leadership time.

Construction and validation of a presenteeism prediction model for ICU nurses in China

Background

Presenteeism, also known as impaired health productivity, refers to the condition of impaired productivity of an individual due to physiological or mental health problems. ICU, as a place of intensive care for patients with acute and critical illnesses, nurses have long faced the nature of work with high loads, high pressures, and high intensities, which makes them a high prevalence group of presenteeism. Presenteeism not only affects the physical and mental health and work wellbeing of nurses but also reduces the quality of nursing services and affects the life safety of patients, such as increasing the risk of falls during hospitalization, increasing the risk of medication errors, and prolonging the hospitalization time of patients. Therefore, early identification and targeted interventions are crucial to reduce presenteeism among ICU nurses.

Objective

This study aimed to construct and validate a predictive model for presenteeism among ICU nurses.

Design

A cross-sectional study.

Methods

1,225 ICU nurses were convened from January to April 2023 from 25 tertiary and secondary hospitals in Sichuan Province, China. ICU nurses were randomly divided into a development set (n = 859) and a validation set (n = 366) according to a 7:3 ratio. Univariate and multifactorial logistic regression analyses were used to determine the influencing factors for presenteeism, and R software was used to construct a column-line graph prediction model. The differentiation and calibration of the predictive model were evaluated by the area under the curve of subjects' work characteristics (ROC) and the Hosmer-Leme-show test, and the clinical decision curve evaluated the clinical validity of the predictive model.

Results

The presenteeism rate of ICU nurses in the development set was 76.8%. Multifactorial logistic regression analysis showed that independent factors affecting ICU nurses' presenteeism included income per month, physical health status, job satisfaction, perceived work stress, perceived social support, transformational leadership, and occupational coping self-efficacy. In the development set and validation set, the area under the ROC curve was 0.821 and 0.786, respectively; the sensitivity and specificity were 80.6, 69.8 and 80.9%, 65.1%, respectively; the Hosmer-Lemeshow goodness-of-fit was χ 2 = 8.076 (p = 0.426) and χ 2 = 5.134 (p = 0.743), respectively, and the model had relatively good discrimination and consistency. The clinical decision curve showed that the model had good clinical validity.

Conclusion

The predictive model of presenteeism risk for ICU nurses constructed in this study has good predictive ability. The model can effectively identify ICU nurses with high presenteeism and provide a reference basis for developing targeted interventions to reduce presenteeism among ICU nurses.

Exploring the Impact of Transformational and Transactional Style of Leadership on Nursing Care Performance and Patient Outcomes

Background

The form of leadership that can positively influence nursing care performance and patient outcomes remains a crucial subject in the healthcare sector.

Aim

This study examines the effect of leadership style at different managerial levels on nursing care performance and patient outcomes.

Methods

A retrospective cohort study was conducted in a public hospital, focusing on two primary settings: the general ward and the critical care unit. The study sample included 60 nurses and 300 patients. The leadership style is a predictor of this study and was measured using a cross-sectional survey of Jordanian nurses using the Multifactor Leadership Questionnaire (MLQ). Nursing care performance and patient outcomes were measured by surveying patients, observing practice, and reviewing health records. The analysis involved descriptive statistics, chi-square tests, odds ratios, and multivariate regression analysis.

Results

The study found that transformational leadership was predominant in the general ward, while transactional leadership was more common in the critical care unit. Leadership styles significantly influence clinical nursing performance. Nurses under transformational leaders were more likely to follow generic policies like patient surveillance but less consistent with specific care standards. Nurses under transactional leaders were linked to higher adherence to standardized care protocols like fall risk assessment and medication rights. Patient outcomes were similar between units, except for higher readmission rates under transactional leadership.

Conclusion

The study's findings underscore the complexities of nurse leadership styles and clinical nursing performance. Nurse manager should adapt their leadership style to the particular setting and a one-size-fits-all approach to leadership may not be effective in healthcare.

Emergency department nurses' intrinsic motivation: A bridge between empowering leadership and thriving at work

BACKGROUND

The relationship between empowering leadership, intrinsic motivation, and thriving at work among emergency department nurses is unclear. Thriving at work can raise employees' job satisfaction and lower their tendency to quit. High workloads and unpleasant workplace experiences may result in emergency department nurses thriving less at work. It has been demonstrated that intrinsic motivation and empowering leadership are both linked to thriving at work in employees.

AIM

To investigate the relationship between empowering leadership and thriving at work among emergency department nurses, as well as the mediating function of intrinsic motivation in this relationship.

METHODS

The 337 emergency department nurses were polled using general information questionnaire, Empowering Leadership Scale, Intrinsic Motivation Scale, and Thriving at Work Scale. Structural equation modeling was used for data analysis.

RESULTS

Positive relationships existed between thriving at work and empowering leadership and intrinsic motivation. Intrinsic motivation was a mediator of the relationship between empowering leadership and thriving at work.

CONCLUSIONS

Intrinsic motivation is one mechanism by which empowering leadership can influence emergency department nurses thriving at work. Nurse managers should adopt an empowering leadership style and take steps to activate the intrinsic motivation of emergency department nurses, thereby increasing nurses' ability to thrive at work.

Transformational Leadership Style and the Quality of Nursing Care in Riyadh Second Health Cluster, Saudi Arabia

Objective

This study aimed to determine the impact of a transformational leadership style on the quality of nursing care in the second health cluster of Riyadh, Saudi Arabia.

Methods

A quantitative cross-sectional research design was used in this investigation. Convenience sampling was used to choose 350 nurses as participants for the investigation. The nurses' perceptions of transformational leadership and the quality of nursing care were evaluated using the Global Transformational Leadership Scale and the Quality Nursing Care Scale. A 52-item online survey that participants self-administered through Google Forms was used to collect data.

Results

The nurses perceived leadership positively and endorsed transformational qualities, with a mean value of 3.87 and a total score of 27.15. The Quality of Nursing Care Scale, which had a total score of 146.5 and a mean of 4.07, indicates nurses' approval of the present quality of care and a holistic approach to patient well-being.

Conclusion

A strong positive link was found between quality of nursing care and transformative leadership.

What factors influencing surgical nurses' competence in implementing person-centered care in the perioperative period?: A cross-sectional study

Strengthening the capability of clinical surgical nurses to provide person-centered care (PCC) requires a thorough analysis of several related factors. This study used a descriptive cross-sectional design to investigate the factors that influence surgical nurses' perioperative competency in the performance of PCC in Anhui, China. A convenience sampling was implemented to administer a questionnaire survey to 437 nurses with more than 1 year of experience working in surgical wards. A web-based cross-sectional questionnaire evaluated the participant's general sociological information, empathy, job burnout, and nursing competence. The questionnaire were designed and published through the online platform Questionnaire Stars, and the link was distributed through the Internet and WeChat media by the nursing department of their hospital. Data were collected from June to September 2023 and processed by descriptive, correlation, and stepwise multiple regression analyses. Participants with high levels of empathy (β  = 0.502, P < .001), low levels of job burnout (β  = -0.288, P < .001), humanistic nursing training (β  = 0.167, P < .001), and personnel agency (β  = 0.083, P < .001) showed better PCC competence. The regression model analysis showed that 4 influencing factors explained 59.2% of the variance (F = 158.930, P < .001, adjusted R2 = 0.592). These findings suggest that steps should be taken to strengthen the key factors, such as improving empathy, minimizing job burnout, offering more humanities training, and enhancing personalities, to reinforce PCC competency.

Investigating the influence of selected leadership styles on patient safety and quality of care: a systematic review and meta-analysis

BACKGROUND

There is a popular belief that transformational leadership (TL) and servant leadership (SL) styles are influential in establishing a patient safety (PS) culture and improving the quality of care (QC). However, there are very few review articles investigating this phenomenon.

PURPOSE

This study performs a systematic review and meta-analysis to ascertain the influences of TL and SL on PS and QC.

METHODS

Published research work indexed in the two popular databases, that is, Scopus and PubMed, was selected based on the inclusion criteria. The systematic review was performed as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data such as country of publication, year, data type, research design, target population, sample size and conclusion were selected from the studies.

RESULTS

There are pieces of evidence suggesting a medium to strong effect of TL on PS. At the same time, the effect of TL on QC is not direct but indirect and is mediated through variables such as fostering positive organisational culture and enhancing organisational outcomes such as job satisfaction, leader effectiveness and willingness of nurses to spend some extra effort. A total of 27 studies were selected for final evaluation and 11 reported a relationship between TL and PS. The 'Fisher r-to-z transformed correlation coefficients' ranged from 0.3769 to 0.8673. Similarly, a total of four studies reported the relationship between TL and QC, 'Fisher r-to-z transformed correlation coefficients' ranged from 0.0802 to 0.5101, with most estimates being positive (80%).

CONCLUSION

TL has a strong and positive effect on PS but a positive and weak effect on the QC. There is not much evidence to establish SL's influence on PS and QC.

The Specialist Nurse in European Healthcare 2030: ESNO Congress 2024 Highlights

The European Specialist Nurses Organization (ESNO), after a series of congresses in Brussels, organised its 6th International Congress in Milan, Italy. The ESNO Congress 2024 focused on "The Specialist Nurse in European Healthcare 2030", addressing the evolving roles and increasing importance of specialist nurses. The event featured keynote presentations and discussions on enhancing clinical practice through advanced education, bridging policy-practice gaps, and improving working conditions. The ESNO Declaration emphasised lifelong learning, harmonised qualification recognition, and interdisciplinary collaboration. A dynamic hackathon preceded the congress, generating innovative solutions to pressing nursing challenges. New inductees of the ESNO Fellowship Program were celebrated. The congress highlighted critical advancements and set a strategic roadmap for the future of specialist nursing in Europe.

Nursing categories' perceptions of the practice environment and quality of care in North West Province: a cross-sectional survey design

BACKGROUND

There is a substantial amount of literature on the perception of the practice environment and quality of care as perceived by registered nurses and community services nurses in South Africa and worldwide, but there is little to no research that could be found regarding other categories of nurses, and how these perceptions differ between the different categories. Therefore, the aim of this study is to describe the different nursing categories' perceptions of the practice environment and quality of care and the association between the variables.

METHODS

This study applied a cross-sectional survey design. Data were collected in April 2021 in the public sector of the North West Province. Multiphase sampling was applied to all categories of nurses who worked in an in-patient unit in the selected hospital for at least 3 months (n = 236).

RESULTS

All nursing categories perceived the practice environment as negative, regarding nurse participation in hospital affairs; nurse manager ability, leadership, and support of nurses and staffing and resource adequacy. Perceived quality of care and patient safety items were perceived as neutral and good. However, in all instances, the perceptions of community service nurses and registered nurses were most negative, and enrolled nurse assistants most positive. Adverse events towards patients and nurses were perceived to only occur a few times a year. Overall, nurse perceptions of quality of care and patient safety were most correlated with the subscale of nurse foundations of quality of care and nurse manager ability, leadership, and support of nurses. Adverse events towards patients were most correlated with the collegial nurse-physician relationship subscale, while adverse events towards nurses were correlated with the foundations of quality of care subscale.

CONCLUSION

Improving the practice environment, especially regarding the subscale nurse foundations of quality of care and nurse manager ability, leadership, and support of nurses, is associated with improved quality of care. Nurses with higher qualifications, registered nurses and community service nurses rated quality of care lower than other categories of nurses, contributing to literature that higher qualified staff are more competent to assess the practice environment and quality of care.

Personal and organisational attributes that support transformational leadership in acute healthcare: scoping review

Objective Transformational leadership benefits both patients and staff. The objective of this scoping review was to explore personal and organisational attributes that support transformational leadership in acute health care. Methods A scoping review was undertaken using Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Medline Complete, PsycInfo and Emerald Insight databases. Search terms were related to transformational leadership and acute care hospitals. Results A total of 18 studies were included: 14 reported personal attributes and 8 reported organisational attributes supporting transformational leadership. The most common personal attributes were manager educational preparation (n  = 5), years of management experience (n  = 4), age (n  = 3) and emotional intelligence (n  = 3). The most common organisational attributes reported were larger organisational size (n  = 2) and culture (n  = 2). Personal (manager) attributes were synthesised into the following categories: demographics, role characteristics, leadership preparation and traits. Organisational attributes were categorised as manager support, organisational characteristics and organisational processes. Conclusions Despite the beneficial outcomes of transformational leadership for patients, staff and organisations, the personal and organisational attributes supporting transformation leadership are not well understood.

Relationship between transformational leadership, adverse patient events, and nurse-assessed quality of care in emergency units: The mediating role of work satisfaction

BACKGROUND

Effective leadership plays a pivotal role in healthcare settings, particularly in the fast-paced and high-pressure environment of the emergency room, as it is closely linked to patient safety and the overall quality of care. This study assessed the mediating role of work satisfaction in the relationship between nurses' perceptions of their nurse managers' transformational leadership, reported adverse patient events, and the nurse-assessed quality of care in the emergency units.

METHODS

A cross-sectional survey design was carried out involving 283 emergency room nurses from the Philippines, utilizing standardized scales. Mediation testing was performed using Hayes' PROCESS macro in SPSS (Model 4).

RESULTS

Emergency room nurses perceived their nurse managers as highly transformational. Nurses' perceptions of transformational leadership in their nurse managers were associated with a reduction in reported adverse patient events and an increase in nurse-assessed nursing care quality. Work satisfaction partially mediated the relationship between transformational leadership and nurse-assessed nursing care quality, but it did not serve as a mediator between transformational leadership and reported adverse patient events.

CONCLUSION

The results suggested that enhancing transformational leadership behaviors among nurse leaders can foster work satisfaction in ER nurses, which, in effect, contributes to enhanced nursing quality of care provision in emergency settings.