Journal of Nursing Management, 2015, 23, 275–278
Editorial Connecting nursing leadership and patient outcomes: state of the science
Current context of efficiency and effectiveness Health care in many countries has undergone rapid and turbulent change over the past three decades including hospital mergers into larger corporations, downsizing hospital beds, moving services out of hospitals into communities, and increasing managerialism in which programs are based on business models promoting fiscal and organizational efficiencies in pursuit of quality improvement (Gilbert 2005, Duncan et al. 2014). This has resulted in significant challenges to optimal patient outcomes through shorter hospital stays, increased waiting times for procedures, service integration to reduce duplication, and implementation of computerized information systems. Changes reflected in restructuring and downsizing have also contributed to the redeployment of many frontline nurses and the elimination of nursing management positions. In many new management models nursing leaders are responsible for multiple clinical programs with larger numbers of staff reporting to them and in some instances were replaced with non-nursing managers (Laschinger et al. 2008). Despite considerable evidence associating features of nursing practice environments, such as staffing, with patient outcomes (Estabrooks et al. 2005, Blegen et al. 2011, Duffield et al. 2011, Aiken et al. 2014), there is much less research examining the effects of nursing leadership on patient outcomes. Some authors have signaled concern for the future of nursing when organizational cultures promote too much focus on efficiencies without a better balance between economics and quality care values and professionals standards (Duncan et al. 2014, Orvik et al. 2015). In practice, we know that effective frontline nurse leaders strive to create this balance while also ensuring adequate resources to realize high quality care. Senior nurse executives play a critical role in inspiring excellence in nursing and strong professional practice environments through policy-making at higher organizational levels (Huston 2008). The continuing economic pressures, health and safety risks DOI: 10.1111/jonm.12307 ª 2015 John Wiley & Sons Ltd
associated with stressful and overloaded work environments, workforce shortages and the impending retirement of a large cohort of nurse leaders mean that attention must be directed to both understanding and developing what is effective nursing leadership and how it is connected to patient outcomes in order to ensure care practices are cost-effective while improving patient outcomes. The purpose of this editorial is to provide a summary of the state of the science on nursing leadership and patient outcomes including discussion of research gaps and issues and implications for practice based on the evidence.
Evidence on the relationship between leadership and patient outcomes We published a systematic review of the research literature (Wong et al. 2013) describing the evidence linking leadership with patient outcomes (updated from Wong & Cummings 2007). Readers are referred to these articles for more details of studies and findings. Patient outcomes included in the reviews were actual primary outcomes extracted from administrative databases or collected prospectively in studies rather than nurse-assessed outcomes. Findings of the final 20 included studies published between 1999 and 2012 represented heightened interest in this topic and supported positive trends identified in the previous review. Most studies were conducted in acute care hospitals but nursing homes and home health care settings were also represented and findings were pooled regardless of the variety of settings.
Leadership theories examined A range of leadership styles were tested but were primarily relational, that is, leader behaviours that are focused on people and relationships to achieve common goals as opposed to a task focus on structures and procedures. Transformational leadership was examined in one-third of the studies, while approaches such as, participative, task- or relationship-oriented, and resonant leadership, and trust in leadership were
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tested in another third of studies. The final third measured leadership as the leader’s ability and support which is a component of several practice environment scales. Patient outcomes were categorized as: patient satisfaction, patient mortality, adverse events and complications and patient health care utilization. Patient mortality and medication errors were the most frequently tested outcomes and overall, 43 relationships between leadership and patient outcomes were found of which 63% (n = 27) were significant.
Summary of the evidence Almost 50% of the studies in the review addressed adverse patient outcomes defined as unintentional injuries or complications associated with clinical management, rather than the patient’s primary condition, resulting in death, disability or extended stay in hospital (Baker et al. 2004). Results showed key relationships between relational leadership and decreased adverse events but findings were strongest for medication errors. Transformational leadership, trust in leadership and manager support were associated with reduced medication errors in four of five studies. Results linking leadership to patient falls and pressure ulcers were mixed. Decreased restraint use and hospital-acquired infections were associated with participative and transformational leadership respectively. Both transformational and resonant leadership styles were related to lower patient mortality in three of six studies. Transformational leadership of unit managers resulted in lower patient mortality through increased retention and expertise of staff which suggests that relationally focused unit managers may affect mortality by creating safe working environments that promote satisfied and high performing staff and establishing adequate staffing and resources to avoid unnecessary deaths. We found significant relationships between both relational and task-oriented leadership and higher patient satisfaction in four of seven studies. Relational (transformational and collaborative) leadership was associated with increased patient satisfaction in acute care and home healthcare settings while task-orientated leadership of nursing home ward managers was positively related to family satisfaction with care and transactional leadership style contributed to increased patient satisfaction in acute care settings. This mixed result suggests that features of each style may contribute to patient satisfaction such as, communicating clear care standards and performance expectations in addition to promoting positive team working 276
relationships or encouraging staff participation in unit decision making. Only three studies were found that measured health care utilization outcomes such as number of hospitalizations, hospital readmissions and patient length of hospital stay and only one study had significant results. Paquet et al. (2013) reported that manager support was related to lower patient length of stay.
Gaps and issues in what we know Although studies showed increasingly rigorous research designs and methods over the past decade, cross-sectional or correlational designs were predominant and considerable variety in patient outcomes and clinical settings hampered greater synthesis of findings. The trend toward more research to test links between leadership and patient outcomes in a broader array of settings such as ambulatory, home care and nursing homes as well as acute care needs to be continued. Research findings were still primarily associations and not confirmed causal connections. Unraveling the complex causal relationships between leadership and patient outcomes, will require intervention and longitudinal studies with repeated observations. While challenging for researchers to carry out due to the level of control necessary, studies of theory-based interventions that change leadership practices and examine the effects on individual, team, unit and organizational outcomes would provide more convincing evidence for and understanding of causal relationships (Gilmartin & D’Aunno 2007). Two other areas of concern were that less than half of the studies tested leadership theories and very few examined processes of leadership influence on outcomes. While it is noteworthy that leadership is now acknowledged as an important antecedent to patient outcomes, the development and testing of robust conceptualizations of leadership that clearly describe leadership behaviours and identify the direct and indirect mechanisms by which leaders affect individuals and outcomes are urgently needed. Many of the studies examined transformational leadership (Bass & Avolio 1994, Kouzes & Posner 1995). However, in a critical analysis of transformational leadership research in nursing, Hutchinson and Jackson (2013) recently argued that flaws in conceptualizations and methods in this body of research call for nurse researchers to pursue “new ways of thinking about nursing leadership” (p. 11) that adequately address the dynamics and contextual drivers in modern day healthcare. Also, we need to move beyond limited notions of ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 275–278
Editorial
leadership such as, manager ability or support, to more multifaceted explanations of leadership behaviour and influence strategies suggested in some of the newer “genre of leadership theories” such as authentic, ethical, servant, shared or resonant leadership (Hannah et al. 2014, p. 599). This field of leadership theories “. . . attempts to determine the forms of leadership behaviours that engage followers and create positive effects that extend beyond task compliance” (Hannah et al. 2014, p. 599). Common aspects of these theories include a focus on the ethical dimension of leadership and the view that followers are active participants in organizational outcomes and maintain selfdetermination. In addition, more research is required that includes the development and testing of leadership theories that encompass leadership of those not in formal leadership roles such as clinical leadership at the point of care or workgroup leadership roles. The mechanisms of leadership effect on patient outcomes is a most challenging aspect of this research topic and to date much is still unknown. Although leaders may directly impact outcomes at multiple levels (individuals, groups or units and organizations) their influence on patient outcomes is most likely indirect working through others and occurring over time (Lord & Dinh 2012). Facilitating changes in working conditions, creating access to resources, guiding individual and team attitudes, behavior and performance, or enabling staff participation in unit and patient care decision making are some potential mechanisms that connect leadership and patient outcomes. Advanced statistical techniques like structural equation modeling are used to explicitly test this complex indirect relationship. For example, transformational leadership was positively related to staff expertise and negatively related to staff turnover both of which contributed to reduced patient mortality and other adverse patient outcomes leading researchers to suggest that strong leaders may retain higher numbers of skilled staff (Houser 2003, Capuano et al. 2005). Additionally, Paquet et al. (2013) showed that manager support was associated with decreased medication errors and patient length of stay through key human resource variables like reduced absenteeism, overtime and nurse/patient ratios. Furthermore, when trust in the leader was high nurses participated more actively in safety organizing behaviours (e.g., discussing errors, questioning current practices) which in turn contributed to fewer medication errors (Vogus & Sutcliffe 2007). While these findings are promising so much more needs to be explored about the mechanisms of leadership influence. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 275–278
Implications for leadership practice Although the evidence base for the connection between leadership and patient outcomes is far from prescriptive, what we do know suggests that positive leadership is pivotal in creating working conditions that optimize nursing practice promoting high quality patient care. Professional work environments that foster strong nursing practice include collaborative teamwork, autonomous decision making, professional development, adequate staffing and skill mix which are most closely aligned with patient safety outcomes (Estabrooks et al. 2005). Although these environments are created by the contributions of both unit leaders and staff, leaders must have the vision, problem solving abilities and the relationship-building skills to navigate the dynamic contexts of organizations to obtain needed resources and support. They also need to engage and empower staff in a way that instills a sense of accountability, confidence and professionalism. With a potential shortage of nursing leaders and nurses, it is imperative that organizations find effective approaches to recruit, develop and retain nursing leaders who can create and implement new models for patient care delivery (Laschinger et al. 2008). Relational leadership styles provide some guidance for the kinds of competencies grounded in relationship-building that new leaders must have as well as the provision of training investment in both existing and potential nurse leaders in organizations. Though managerial competencies are important, leaders who are skilled in emotional intelligence have the ability to monitor their own and others’ emotions, use this information to build solid working relationships and are assets to the system. A relational approach to leadership contributes to healthy work environments through support, open and honest communication and trust. Managers who are concerned about the well-being of their staff, listen to and acknowledge their input, respond openly and truthfully to concerns, and act on values that support exemplary patient care are more apt to garner nurses’ trust. Trustworthy managers inspire nurses’ commitment and pride in work which may be demonstrated in willingness to engage in new practices, voice patient issues, and make suggestions for workplace changes (Wong & Cummings 2009). Leaders who create opportunities for meaningful dialogue with nurses to resolve care issues that risk patient safety and then follow through on staff suggestions for improvement role model their commitment to patient care. 277
Editorial
Conclusion The research evidence highlights a clear connection between supportive leadership approaches and positive patient safety outcomes (lower medication errors, nosocomial infections and patient mortality) and higher patient satisfaction; however, future longitudinal and interventional studies testing sound leadership theories that include mechanisms of leadership influence must be conducted in a variety of healthcare settings to establish a stronger evidence base. Research findings also suggest that leaders’ value for and knowledge of patient care requirements, the quality of their interpersonal skills and their facilitation of healthy working conditions and engagement in leadership behaviours that inspire nursing teams to higher levels of performance are important predictors of improved patient outcomes. Carol A. Wong, R N , P h D Associate Professor, Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Rm. H27, Health Sciences Addition (HSA), The University of Western Ontario, London, Ontario, Canada E-mail: [email protected]
References Aiken L.H., Sloane D.M., Bruyneel L., Van den Heede K., Griffiths P., Busse R. (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet 383 (9931), 1824–1830. Baker G.R., Norton P.G., Flintoft V. et al. (2004) The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal 170 (11), 1678–1686. Bass B.M. & Avolio B.J. (1994) Improving Organizational Effectiveness through Transformational Leadership. Sage, California. Blegen M.A., Goode C.J., Spetz J., Vaughn T. & Park S.H. (2011) Nurse staffing effects on patient outcomes: safety-net and non-safety-net hospitals. Medical Care 49 (4), 406–414. Capuano T., Bokovoy J., Hitchings K. & Houser J. (2005) Use of a validated model to evaluate the impact of the work environment on outcomes at a magnet hospital. Health Care Management Review 30 (3), 229–236. Duffield C., Diers D., O’Brien-Pallas L. et al. (2011) Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research 24, 244–255. Duncan S., Rodney P.A. & Thorne S. (2014) Forging a strong nursing future: insights from the Canadian context. Journal of Research in Nursing 19 (7–8), 621–633.
278
Estabrooks C. A., Midodzi W. K., Cummings G. G., Ricker K. L. & Giovannetti P. (2005) The impact of hospital nursing characteristics on 30-day mortality. Nursing Research 54 (2), 74Y84. Gilbert T.P. (2005) Trust and managerialism: exploring discourses of care. Journal of Advanced Nursing 52 (4), 454– 463. Gilmartin M. & D’Aunno T.A. (2007) Chapter 8: leadership research in healthcare. The Academy of Management Annals 1 (1), 387–438. Hannah S.T., Sumanth J.J., Lester P. & Cavarretta F. (2014) Debunking the false dichotomy of leadership idealism and pragmatism: critical evaluation and support of newer genre leadership theories. Journal of Organizational Behavior 35 (5), 598–621. Houser J. (2003) A model for evaluating the context of nursing care delivery. Journal of Nursing Administration 33 (1), 39– 47. Huston C. (2008) Preparing nurse leaders for 2010. Journal of Nursing Management 16, 905–911. Hutchinson M. & Jackson D. (2013) Transformational leadership in nursing: towards a more critical interpretation. Nursing Inquiry 20 (1), 11–22. Kouzes J.M. & Posner B.Z. (1995) The Leadership Challenge: How to Get Extraordinary Things Done in Organizations, 2nd edn. Jossey-Bass Publishing, San Francisco, CA. Laschinger H.K., Wong C.A., Ritchie J. et al. (2008) A profile of the structure and impact of nursing management in Canadian hospitals. Healthcare Quarterly 11 (2), 85–94. Lord R.G. & Dinh J.E. (2012) Aggregation processes and levels of analysis as organizing structures for leadership theories. In The Nature of Leadership, 2nd edn(D.V. Day & J. Antonakis eds), pp. 29–65. Sage Publications Inc., Thousand Oaks, CA. Orvik A., V agen S.R., Axelsson S.B. & Axelsson R. (2015) Quality, efficiency and integrity: value squeezes in management of hospital wards. Journal of Nursing Management 23 (1), 65–74. Paquet M., Courcy F., Lavoie-Tremblay M., Gagnon S. & Maillet S. (2013) Psychosocial work environment and prediction of quality of care indicators in one Canadian health center. Worldviews on Evidence-Based Nursing 10 (2), 82–94. Vogus T.J. & Sutcliffe K.M. (2007) The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. Medical Care 45 (10), 997–1002. Wong C.A. & Cummings G.G. (2007) The relationship between nursing leadership and patient outcomes: a systematic review. Journal of Nursing Management 15 (5), 508–521. Wong C.A. & Cummings G.G. (2009) The influence of authentic leadership behaviours on trust and work outcomes in healthcare staff. Journal of Leadership Studies 3 (2), 6–23. Wong C.A., Cummings G.G. & Ducharme L. (2013) The relationship between nursing leadership and patient outcomes: a systematic review update. Journal of Nursing Management 21, 709–724.
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 275–278
Editorial Connecting nursing leadership and patient outcomes: state of the science
Current context of efficiency and effectiveness Health care in many countries has undergone rapid and turbulent change over the past three decades including hospital mergers into larger corporations, downsizing hospital beds, moving services out of hospitals into communities, and increasing managerialism in which programs are based on business models promoting fiscal and organizational efficiencies in pursuit of quality improvement (Gilbert 2005, Duncan et al. 2014). This has resulted in significant challenges to optimal patient outcomes through shorter hospital stays, increased waiting times for procedures, service integration to reduce duplication, and implementation of computerized information systems. Changes reflected in restructuring and downsizing have also contributed to the redeployment of many frontline nurses and the elimination of nursing management positions. In many new management models nursing leaders are responsible for multiple clinical programs with larger numbers of staff reporting to them and in some instances were replaced with non-nursing managers (Laschinger et al. 2008). Despite considerable evidence associating features of nursing practice environments, such as staffing, with patient outcomes (Estabrooks et al. 2005, Blegen et al. 2011, Duffield et al. 2011, Aiken et al. 2014), there is much less research examining the effects of nursing leadership on patient outcomes. Some authors have signaled concern for the future of nursing when organizational cultures promote too much focus on efficiencies without a better balance between economics and quality care values and professionals standards (Duncan et al. 2014, Orvik et al. 2015). In practice, we know that effective frontline nurse leaders strive to create this balance while also ensuring adequate resources to realize high quality care. Senior nurse executives play a critical role in inspiring excellence in nursing and strong professional practice environments through policy-making at higher organizational levels (Huston 2008). The continuing economic pressures, health and safety risks DOI: 10.1111/jonm.12307 ª 2015 John Wiley & Sons Ltd
associated with stressful and overloaded work environments, workforce shortages and the impending retirement of a large cohort of nurse leaders mean that attention must be directed to both understanding and developing what is effective nursing leadership and how it is connected to patient outcomes in order to ensure care practices are cost-effective while improving patient outcomes. The purpose of this editorial is to provide a summary of the state of the science on nursing leadership and patient outcomes including discussion of research gaps and issues and implications for practice based on the evidence.
Evidence on the relationship between leadership and patient outcomes We published a systematic review of the research literature (Wong et al. 2013) describing the evidence linking leadership with patient outcomes (updated from Wong & Cummings 2007). Readers are referred to these articles for more details of studies and findings. Patient outcomes included in the reviews were actual primary outcomes extracted from administrative databases or collected prospectively in studies rather than nurse-assessed outcomes. Findings of the final 20 included studies published between 1999 and 2012 represented heightened interest in this topic and supported positive trends identified in the previous review. Most studies were conducted in acute care hospitals but nursing homes and home health care settings were also represented and findings were pooled regardless of the variety of settings.
Leadership theories examined A range of leadership styles were tested but were primarily relational, that is, leader behaviours that are focused on people and relationships to achieve common goals as opposed to a task focus on structures and procedures. Transformational leadership was examined in one-third of the studies, while approaches such as, participative, task- or relationship-oriented, and resonant leadership, and trust in leadership were
275
Editorial
tested in another third of studies. The final third measured leadership as the leader’s ability and support which is a component of several practice environment scales. Patient outcomes were categorized as: patient satisfaction, patient mortality, adverse events and complications and patient health care utilization. Patient mortality and medication errors were the most frequently tested outcomes and overall, 43 relationships between leadership and patient outcomes were found of which 63% (n = 27) were significant.
Summary of the evidence Almost 50% of the studies in the review addressed adverse patient outcomes defined as unintentional injuries or complications associated with clinical management, rather than the patient’s primary condition, resulting in death, disability or extended stay in hospital (Baker et al. 2004). Results showed key relationships between relational leadership and decreased adverse events but findings were strongest for medication errors. Transformational leadership, trust in leadership and manager support were associated with reduced medication errors in four of five studies. Results linking leadership to patient falls and pressure ulcers were mixed. Decreased restraint use and hospital-acquired infections were associated with participative and transformational leadership respectively. Both transformational and resonant leadership styles were related to lower patient mortality in three of six studies. Transformational leadership of unit managers resulted in lower patient mortality through increased retention and expertise of staff which suggests that relationally focused unit managers may affect mortality by creating safe working environments that promote satisfied and high performing staff and establishing adequate staffing and resources to avoid unnecessary deaths. We found significant relationships between both relational and task-oriented leadership and higher patient satisfaction in four of seven studies. Relational (transformational and collaborative) leadership was associated with increased patient satisfaction in acute care and home healthcare settings while task-orientated leadership of nursing home ward managers was positively related to family satisfaction with care and transactional leadership style contributed to increased patient satisfaction in acute care settings. This mixed result suggests that features of each style may contribute to patient satisfaction such as, communicating clear care standards and performance expectations in addition to promoting positive team working 276
relationships or encouraging staff participation in unit decision making. Only three studies were found that measured health care utilization outcomes such as number of hospitalizations, hospital readmissions and patient length of hospital stay and only one study had significant results. Paquet et al. (2013) reported that manager support was related to lower patient length of stay.
Gaps and issues in what we know Although studies showed increasingly rigorous research designs and methods over the past decade, cross-sectional or correlational designs were predominant and considerable variety in patient outcomes and clinical settings hampered greater synthesis of findings. The trend toward more research to test links between leadership and patient outcomes in a broader array of settings such as ambulatory, home care and nursing homes as well as acute care needs to be continued. Research findings were still primarily associations and not confirmed causal connections. Unraveling the complex causal relationships between leadership and patient outcomes, will require intervention and longitudinal studies with repeated observations. While challenging for researchers to carry out due to the level of control necessary, studies of theory-based interventions that change leadership practices and examine the effects on individual, team, unit and organizational outcomes would provide more convincing evidence for and understanding of causal relationships (Gilmartin & D’Aunno 2007). Two other areas of concern were that less than half of the studies tested leadership theories and very few examined processes of leadership influence on outcomes. While it is noteworthy that leadership is now acknowledged as an important antecedent to patient outcomes, the development and testing of robust conceptualizations of leadership that clearly describe leadership behaviours and identify the direct and indirect mechanisms by which leaders affect individuals and outcomes are urgently needed. Many of the studies examined transformational leadership (Bass & Avolio 1994, Kouzes & Posner 1995). However, in a critical analysis of transformational leadership research in nursing, Hutchinson and Jackson (2013) recently argued that flaws in conceptualizations and methods in this body of research call for nurse researchers to pursue “new ways of thinking about nursing leadership” (p. 11) that adequately address the dynamics and contextual drivers in modern day healthcare. Also, we need to move beyond limited notions of ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 275–278
Editorial
leadership such as, manager ability or support, to more multifaceted explanations of leadership behaviour and influence strategies suggested in some of the newer “genre of leadership theories” such as authentic, ethical, servant, shared or resonant leadership (Hannah et al. 2014, p. 599). This field of leadership theories “. . . attempts to determine the forms of leadership behaviours that engage followers and create positive effects that extend beyond task compliance” (Hannah et al. 2014, p. 599). Common aspects of these theories include a focus on the ethical dimension of leadership and the view that followers are active participants in organizational outcomes and maintain selfdetermination. In addition, more research is required that includes the development and testing of leadership theories that encompass leadership of those not in formal leadership roles such as clinical leadership at the point of care or workgroup leadership roles. The mechanisms of leadership effect on patient outcomes is a most challenging aspect of this research topic and to date much is still unknown. Although leaders may directly impact outcomes at multiple levels (individuals, groups or units and organizations) their influence on patient outcomes is most likely indirect working through others and occurring over time (Lord & Dinh 2012). Facilitating changes in working conditions, creating access to resources, guiding individual and team attitudes, behavior and performance, or enabling staff participation in unit and patient care decision making are some potential mechanisms that connect leadership and patient outcomes. Advanced statistical techniques like structural equation modeling are used to explicitly test this complex indirect relationship. For example, transformational leadership was positively related to staff expertise and negatively related to staff turnover both of which contributed to reduced patient mortality and other adverse patient outcomes leading researchers to suggest that strong leaders may retain higher numbers of skilled staff (Houser 2003, Capuano et al. 2005). Additionally, Paquet et al. (2013) showed that manager support was associated with decreased medication errors and patient length of stay through key human resource variables like reduced absenteeism, overtime and nurse/patient ratios. Furthermore, when trust in the leader was high nurses participated more actively in safety organizing behaviours (e.g., discussing errors, questioning current practices) which in turn contributed to fewer medication errors (Vogus & Sutcliffe 2007). While these findings are promising so much more needs to be explored about the mechanisms of leadership influence. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 275–278
Implications for leadership practice Although the evidence base for the connection between leadership and patient outcomes is far from prescriptive, what we do know suggests that positive leadership is pivotal in creating working conditions that optimize nursing practice promoting high quality patient care. Professional work environments that foster strong nursing practice include collaborative teamwork, autonomous decision making, professional development, adequate staffing and skill mix which are most closely aligned with patient safety outcomes (Estabrooks et al. 2005). Although these environments are created by the contributions of both unit leaders and staff, leaders must have the vision, problem solving abilities and the relationship-building skills to navigate the dynamic contexts of organizations to obtain needed resources and support. They also need to engage and empower staff in a way that instills a sense of accountability, confidence and professionalism. With a potential shortage of nursing leaders and nurses, it is imperative that organizations find effective approaches to recruit, develop and retain nursing leaders who can create and implement new models for patient care delivery (Laschinger et al. 2008). Relational leadership styles provide some guidance for the kinds of competencies grounded in relationship-building that new leaders must have as well as the provision of training investment in both existing and potential nurse leaders in organizations. Though managerial competencies are important, leaders who are skilled in emotional intelligence have the ability to monitor their own and others’ emotions, use this information to build solid working relationships and are assets to the system. A relational approach to leadership contributes to healthy work environments through support, open and honest communication and trust. Managers who are concerned about the well-being of their staff, listen to and acknowledge their input, respond openly and truthfully to concerns, and act on values that support exemplary patient care are more apt to garner nurses’ trust. Trustworthy managers inspire nurses’ commitment and pride in work which may be demonstrated in willingness to engage in new practices, voice patient issues, and make suggestions for workplace changes (Wong & Cummings 2009). Leaders who create opportunities for meaningful dialogue with nurses to resolve care issues that risk patient safety and then follow through on staff suggestions for improvement role model their commitment to patient care. 277
Editorial
Conclusion The research evidence highlights a clear connection between supportive leadership approaches and positive patient safety outcomes (lower medication errors, nosocomial infections and patient mortality) and higher patient satisfaction; however, future longitudinal and interventional studies testing sound leadership theories that include mechanisms of leadership influence must be conducted in a variety of healthcare settings to establish a stronger evidence base. Research findings also suggest that leaders’ value for and knowledge of patient care requirements, the quality of their interpersonal skills and their facilitation of healthy working conditions and engagement in leadership behaviours that inspire nursing teams to higher levels of performance are important predictors of improved patient outcomes. Carol A. Wong, R N , P h D Associate Professor, Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Rm. H27, Health Sciences Addition (HSA), The University of Western Ontario, London, Ontario, Canada E-mail: [email protected]
References Aiken L.H., Sloane D.M., Bruyneel L., Van den Heede K., Griffiths P., Busse R. (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet 383 (9931), 1824–1830. Baker G.R., Norton P.G., Flintoft V. et al. (2004) The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal 170 (11), 1678–1686. Bass B.M. & Avolio B.J. (1994) Improving Organizational Effectiveness through Transformational Leadership. Sage, California. Blegen M.A., Goode C.J., Spetz J., Vaughn T. & Park S.H. (2011) Nurse staffing effects on patient outcomes: safety-net and non-safety-net hospitals. Medical Care 49 (4), 406–414. Capuano T., Bokovoy J., Hitchings K. & Houser J. (2005) Use of a validated model to evaluate the impact of the work environment on outcomes at a magnet hospital. Health Care Management Review 30 (3), 229–236. Duffield C., Diers D., O’Brien-Pallas L. et al. (2011) Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research 24, 244–255. Duncan S., Rodney P.A. & Thorne S. (2014) Forging a strong nursing future: insights from the Canadian context. Journal of Research in Nursing 19 (7–8), 621–633.
278
Estabrooks C. A., Midodzi W. K., Cummings G. G., Ricker K. L. & Giovannetti P. (2005) The impact of hospital nursing characteristics on 30-day mortality. Nursing Research 54 (2), 74Y84. Gilbert T.P. (2005) Trust and managerialism: exploring discourses of care. Journal of Advanced Nursing 52 (4), 454– 463. Gilmartin M. & D’Aunno T.A. (2007) Chapter 8: leadership research in healthcare. The Academy of Management Annals 1 (1), 387–438. Hannah S.T., Sumanth J.J., Lester P. & Cavarretta F. (2014) Debunking the false dichotomy of leadership idealism and pragmatism: critical evaluation and support of newer genre leadership theories. Journal of Organizational Behavior 35 (5), 598–621. Houser J. (2003) A model for evaluating the context of nursing care delivery. Journal of Nursing Administration 33 (1), 39– 47. Huston C. (2008) Preparing nurse leaders for 2010. Journal of Nursing Management 16, 905–911. Hutchinson M. & Jackson D. (2013) Transformational leadership in nursing: towards a more critical interpretation. Nursing Inquiry 20 (1), 11–22. Kouzes J.M. & Posner B.Z. (1995) The Leadership Challenge: How to Get Extraordinary Things Done in Organizations, 2nd edn. Jossey-Bass Publishing, San Francisco, CA. Laschinger H.K., Wong C.A., Ritchie J. et al. (2008) A profile of the structure and impact of nursing management in Canadian hospitals. Healthcare Quarterly 11 (2), 85–94. Lord R.G. & Dinh J.E. (2012) Aggregation processes and levels of analysis as organizing structures for leadership theories. In The Nature of Leadership, 2nd edn(D.V. Day & J. Antonakis eds), pp. 29–65. Sage Publications Inc., Thousand Oaks, CA. Orvik A., V agen S.R., Axelsson S.B. & Axelsson R. (2015) Quality, efficiency and integrity: value squeezes in management of hospital wards. Journal of Nursing Management 23 (1), 65–74. Paquet M., Courcy F., Lavoie-Tremblay M., Gagnon S. & Maillet S. (2013) Psychosocial work environment and prediction of quality of care indicators in one Canadian health center. Worldviews on Evidence-Based Nursing 10 (2), 82–94. Vogus T.J. & Sutcliffe K.M. (2007) The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. Medical Care 45 (10), 997–1002. Wong C.A. & Cummings G.G. (2007) The relationship between nursing leadership and patient outcomes: a systematic review. Journal of Nursing Management 15 (5), 508–521. Wong C.A. & Cummings G.G. (2009) The influence of authentic leadership behaviours on trust and work outcomes in healthcare staff. Journal of Leadership Studies 3 (2), 6–23. Wong C.A., Cummings G.G. & Ducharme L. (2013) The relationship between nursing leadership and patient outcomes: a systematic review update. Journal of Nursing Management 21, 709–724.
ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 275–278
