1. Context
Leadership is the process of influencing people to achieve common goals (1). In other words, leadership is a process of social influence in which leaders use interpersonal behaviors to motivate their followers to do their best for the group to achieve its goals (2). Nursing leadership is increasingly discussed in the literature, as it directly influences nurses’ job satisfaction and retention and, consequently, the quality of care (3-6). When nurses are satisfied with their leaders, they are more motivated; on the other hand, under toxic leadership, nurses tend to be frustrated with the profession, which increases turnover intention (5) and decreases the quality of care (3). It must be emphasized that nursing turnover has economic and non-economic consequences, threatening the safety of patients and nurses and thus interfering with the success of health institutions (3, 7). Nurse leaders, therefore, have important roles in motivating their teams and developing a safe work environment (8).
Nurses perform functions related to care, education, research, and management (9, 10). However, caring is the basic talent of nurses, and all other functions they perform aim to make care increasingly efficient and effective (9). Many factors can affect the quality of care, including nursing leadership (3). Leadership is emphasized in all nurses’ roles (4, 8, 11). Nurses can adopt several different leadership styles when leading their teams. Democratic, autocratic, authentic, servant, transactional, and transformational leadership are among these different styles (1). However, in the nursing field, transformational leadership is one of the most discussed styles (1, 12, 13), and in many studies, it is pointed out as the style preferred by nurses (5, 12) because transformational leaders seek to motivate, inspire and empower their followers so that they too gain leadership competence (1, 11).
While leading, nurses must adopt ethical attitudes, which will be reflected in team members; leaders must, therefore, be role models for others (14). Ethical leaders are fair and honest; they respect others and lead by example (15). Nurses’ ethical behaviors and leadership competence are pivotal to creating a favorable work environment for quality and safe patient care (3, 16).
Although leadership is a skill that improves over time, nursing students must receive leadership education through creative and innovative methods (17), as leadership knowledge will be necessary when providing care, managing the nursing team, training other nurses, and developing research in the field of nursing (9).
The healthcare system is constantly changing, and nurses, who are critical to the success of the healthcare industry, play various roles in which they must exercise leadership. Nurse leaders are scientists, educators, and caregivers who inspire their followers (18). Understanding that leadership is important in all nurse functions, the need to explore the last ten years of scientific literature on the different aspects of leadership in nursing was identified. It was determined that learning about nurses’ experiences would be appropriate to better explore the different dimensions of nursing leadership; therefore, only qualitative studies were selected. Qualitative approaches are used to analyze the lived experience of individuals (19).
2. Objective
This study aimed to explore the scientific literature concerning different aspects of leadership in nursing.
3. Methods
3.1. Design
The Whittemore and Knafl (20) framework were used to carry out this integrative review of qualitative studies; first, the problem was identified, then the literature was searched, then data was evaluated and analyzed, and finally, the results were presented. Qualitative studies address a specific event, process, or phenomenon experienced by individuals (19, 21); thus, selecting qualitative studies was considered more appropriate for identifying different aspects of nursing leadership.
3.2. Search Strategy
The search for original primary qualitative research articles on nursing leadership published in the last ten years (2013 - 2022) was carried out in July 2022. The articles were searched by titles using the descriptors “qualitative,” “leadership,” and “nursing” linked by the Boolean operator AND. The search was conducted on Google Scholar, Medline, PubMed, and Scopus. These databases were chosen due to the ease of access and because they include many publications (22-24). Although the search was not limited by the publication language, the descriptors used for searches were written in English.
3.3. Inclusion and Exclusion Criteria
Original primary qualitative research articles reporting nursing leadership, with full texts available on the Internet, were included. Studies that did not address nursing leadership and non-qualitative studies were excluded.
3.4. Data Extraction
Sixty-three studies were found through the four electronic databases, 40 duplicate articles were excluded, and the result decreased to 23. Abstracts were screened for the remaining articles, and 12 articles were excluded for not matching the objective of the study. A total of 11 articles were read in full and were included in the quality assessment. The research flowchart is shown in Figure 1.
Figure 1.
Research flowchart
3.5. Quality Assessment
The quality of the studies was evaluated through the Critical Appraisal Skills Program (CASP) (25). The CASP is used to evaluate qualitative studies through 10 main questions. These questions assess the clearness of the study, the suitability of the methodology, the participants’ selection process, the data collection methods, the relationship between researcher and participants, ethical considerations, the rigor of data analysis, the presentation of results, and the importance of the study (25). The questions were rated as “yes” (2 points), “unclear” (1 point), or “no” (0 points). The selected articles scored between 16 and 20 points. The most common weaknesses found in the articles were unclear information about the relationship between researchers and participants and a lack of justification for choosing the qualitative approach. No articles were excluded based on critical assessment; all 11 evaluated articles were included in this review (Table 1).
Table 1.Evaluation of the Quality of Articles According to the Critical Appraisal Skills Programme (CASP) a
| Reference | Questions a | Quality Score | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | ||
| Bahlman-van Ooijen et al. (26), 2022 | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 20 = 100 |
| Barkhordari-Sharifabad et al. (27), 2018 | Y | Y | Y | U | Y | U | Y | Y | Y | Y | 18 = 0.90 |
| Barkhordari-Sharifabad et al. (28), 2017 | Y | Y | U | U | Y | N | Y | Y | Y | Y | 16 = 0.80 |
| Barkhordari-Sharifabad et al. (29), 2018 | Y | Y | U | U | Y | N | Y | Y | Y | Y | 16 = 0.80 |
| Démeh and Rosengren (30), 2015 | Y | Y | Y | Y | Y | N | Y | Y | Y | Y | 18 = 0.90 |
| Ha and Pepin (31), 2017 | Y | Y | Y | Y | Y | U | Y | Y | Y | Y | 19 = 0.95 |
| Ha and Pepin (32), 2018 | Y | Y | Y | Y | Y | N | Y | Y | Y | Y | 18 = 0.90 |
| Harvey et al. (33), 2019 | Y | Y | Y | Y | Y | U | Y | Y | Y | Y | 19 = 0.95 |
| Kim et al. (34), 2022 | Y | Y | Y | Y | Y | N | Y | Y | Y | Y | 18 = 0.90 |
| Mannix et al. (35), 2015 | Y | Y | U | Y | Y | N | Y | Y | Y | Y | 17 = 0.85 |
| Tinkler and Robinson (36), 2020 | Y | Y | Y | Y | Y | U | Y | Y | Y | Y | 19 = 0.95 |
a Critical Appraisal Skills Programme (CASP) checklist is a 10-question tool used to evaluate qualitative studies (CASP, 2018).
3.6. Data Analysis
A form containing the following headings: authors/year of publication, country, journal, sample, type of study, data collection, main findings, and limitations were used to extract general information from the included articles. Important information is shown in the quality assessment (Table 1) and summary table (Table 2). Data were analyzed through qualitative content analysis, which is used in integrative reviews to share new information based on synthesizing results from previous original studies (37). The included articles were read several times; information was compared, and similar information was coded and organized by categories. Codes identified through data comparison were presented in three categories: (1) the Importance of nursing leadership and leaders’ roles; (2) ethical leadership; and (3) nursing leadership education.
Table 2.Summary of the Characteristics and Findings of the Included Studies
| Authors/Year of Publication | Countries | Journal | Sample | Type of Study/Data Collection | Main Findings | Limitations |
|---|---|---|---|---|---|---|
| Bahlman-van Ooijen et al. (26), 2022 | Netherlands | Journal of Advanced Nursing | Twelve nurses | Ethnography/Semi-structured interviews | Findings were presented into six main themes related to leadership, patient participation and preferences, relationships, task-focused nursing, and role modeling. | Data saturation was not mentioned. |
| Barkhordari-Sharifabad et al. (27), 2018 | Iran | Journal of Medical Ethics and History of Medicine | Fourteen nurse managers and educators | Phenomenological/Semi-structured interviews | Three main themes emerged: ethical, cultural, and managerial problems. | Unclear information about the recruitment of participants; and the relationship researcher-participants |
| Barkhordari-Shariabad et al. (28), 2017 | Iran | Electronic Physician | Fourteen nurse managers and nursing instructors | Phenomenological/ Semi-structured interviews | Two main themes emerged: leader as mentor and professional insight | The choice of method was not clearly justified; Unclear participants’ recruitment; Lack of information regarding the researcher-participant relationship |
| Barkhordari-Sharifabad et al. (29), 2018 | Iran | Nursing Ethics | Fourteen nursing faculty members and nurse managers | Phenomenological/Semi-structured interviews | Findings were presented in two main themes related to satisfaction and productivity. | Does not clearly justify the choice of method; Unclear participants’ recruitment; Lack of information regarding the researcher-participant relationship |
| Démeh and Rosengren (30), 2015 | Jordan | Nurse Education Today | Twenty nursing students | Narrative/Written narratives | Findings were presented under one main theme related to clinical leadership and safety. | Data collection procedure; Lack of information regarding the researcher-participant relationship |
| Ha and Pepin (31), 2017 | Canada | Nurse Education Today | Five undergraduate nursing students, four nursing educators, and the principal investigator | Phenomenological/Documents from team meetings, the principal investigator’s field notes, and a focus group | Findings were presented under two main themes related to collaboration and changes. | Potential bias since the principal investigator was also a participant |
| Ha and Pepin (32), 2018 | Canada | Nurse Education in Practice | Twenty-three students and six educators | Phenomenological/Semi-structured interviews and focus groups | Findings were presented under three themes: visual examples, role models, and group discussions. | Data saturation was not mentioned; Lack of information regarding the researcher-participant relationship. |
| Harvey et al. (33), 2019 | Australia, Canada, England, and Sweden | International Journal of Nursing Studies | Fifty-five nurses leaders | Phenomenological/Semi-structured interviews | Three main themes emerged: different mechanisms for evidence-based practice (EBP), roles shaped by context, and challenges of leading EBP. | Unclear information regarding the researcher-participant relationship |
| Kim et al. (34), 2022 | South Korea | Journal of Nursing Management | Fifteen nurse leaders | Phenomenological/Individual interviews and focus groups | Findings were presented under five main themes related to nursing leadership: commitment and abilities, and leadership education: importance, difficulties, and strategies | Lack of information regarding the researcher-participant relationship |
| Mannix et al. (35), 2015 | Australia | Journal of Clinical Nursing | Twelve nurse leaders | Phenomenological/Semi-structured interviews | Findings were presented according to three main themes related to practice, ethical leadership, and fair/just solutions. | The choice of method was not clearly justified; Lack of information regarding the researcher-participant relationship. |
| Tinkler and Robinson (36), 2020 | United Kingdom | Journal of Research in Nursing | Twenty-seven Clinical Research Nurses | Phenomenological/Individual interviews and focus groups | Two main themes emerged: self-leadership and leadership culture | Unclear information regarding the researcher-participant relationship |
4. Results
Although the search for studies was not limited by the publication language, all the articles included in this review were published in English. The 11 selected studies are from ten different journals. Four studies (36.36%) were published in 2017. The samples were very varied; studies were conducted with nurses, nurse leaders, nurse educators, nurse researchers, and nursing students. Nine studies (81.82%) were phenomenological. The number of participants varied from 10 to 55 individuals. Studies were conducted in Iran (n = 3), Canada (n = 2), Australia (n = 1), Jordan (n = 1), South Korea (n = 1), the Netherlands (n = 1), the United Kingdom (n = 1), and one study was conducted with nurse leaders from four different countries: Australia, Canada, England, and Sweden. In six studies, the majority of participants were female (26, 27, 29-32); in one study, all participants were female (34); in three studies, gender was not mentioned (33, 35, 36); and in one study the majority of participants (57,14%) were male (28).
A total of four studies had the main objective related to ethical nursing leadership (27 - 29, 35), three articles had clinical nursing leadership as the main theme (30 - 32), one article aimed to identify nursing leadership behaviors that facilitate patients' participation in care (26), one article addressed nursing leadership education and practice (34), one article was about leadership and evidence-based practices (33), and the remaining article was conducted to explore the influence of individual and organizational leadership on nursing research delivery (36). The participants' perceptions regarding the different aspects of nursing leadership are present in the findings of all 11 studies. The findings of the present review were organized into three categories: (1) the importance of nursing leadership and leaders' roles; (2) ethical leadership; and (3) nursing leadership education.
4.1. Importance of Nursing Leadership and Leaders’ Roles
According to the analyzed literature, nurse leaders are supportive (30, 34), passionate, committed (35), competent, reflective, enthusiastic, inspiring, and critical professionals (26) who are responsible for care in all its dimensions (26, 34), thus nurse leaders are always looking for new knowledge and skills (26, 28), and they are also mentors and monitors who share knowledge and information (30, 33) and provide directions to other team members (33). The role of nursing leaders in collecting data to create policies and procedures and developing evidence-based practice was also reported (33). In addition, the importance of providing feedback while leading the nursing team to ensure the development of staff (33) and the success of the institution was identified (33, 34). The studies emphasized that nurse leaders are responsible for motivating their teams (26, 34), supervising nurses and nursing students, thus ensuring patient safety (26), and encouraging patients to play an active role in the care process (26, 30).
According to nurses, leadership is a skill acquired over time through experience and analysis of different leadership styles (26). It was emphasized that skills such as problem-solving, interpersonal relationships, empathetic communication, and organizational management are crucial for nurse leaders (34). In addition, communication (26, 30) and training were important points in improving nursing leadership (26).
The importance of role models was addressed in two different ways, as nurses need a role model when exercising leadership (26), and they must also be role models for other team members by adopting ethical leadership (28, 29, 33). The importance of having a nursing leadership model seems to be crucial since nurses and nursing students pointed out this need during internships when they were being trained in clinical nursing leadership (30). It was reported that nurse leaders motivate staff nurses through ethical behaviors (29). Therefore, nurse leaders' attitudes influence the satisfaction and productivity of the nursing team, consequently reflecting the quality of care (26, 29). As nurse leaders are important for caring in different dimensions, they are crucial for promoting nursing as a profession valued by society (26, 29).
Studies emphasized the importance of leadership for care, management, education, and research in the field of nursing. According to the studies included in this review, nursing leadership is essential in implementing evidence-based practice (33). In addition, nurses' attitudes as leaders influence patients' participation in the care process (26). Ethical behaviors of nursing managers reflect on the satisfaction of the nursing team and the quality of care since nurses are more motivated in the presence of ethical leadership (27-29, 35). Therefore, the importance of teaching leadership in nursing schools was emphasized (34), and clinical leadership was identified as an important tool for training competent nurses (30-32). Self-leadership and organizational leadership were pointed out as fundamental factors for clinical research success in nursing (36).
4.2. Ethical Leadership
Ethical leadership was mentioned in several articles included in this review (27-30, 34, 35). According to the scientific literature, when adopting ethical leadership, nurse leaders manage to achieve inner satisfaction while increasing the satisfaction of staff nurses and patients (29) since honesty, fairness, flexibility, and respect for other team members lead to self-satisfaction (29), and when the nursing leader treats all team members equally, nurses are empowered (28, 34, 35), and work more satisfied, thus care is positively affected (29). In other words, one of the important roles of nursing leaders is to build ethical work environments (30, 34).
However, nurse managers may face barriers in adopting ethical leadership, as other team members may have varied opinions regarding the leader’s attitudes; in addition, some leaders report that the team may try to take advantage when faced with a more flexible and friendly leader; thus, some leaders mentioned being bullied and abused while seeking to lead ethically (27). Moreover, social culture (27) and organizational culture were pointed out by nurse managers as obstacles to ethical leadership (27, 35). According to nursing leaders, negative societal perceptions of the nursing profession, lack of organizational democracy (27), and some organizational policies and procedures, such as restrictions on patient visits, can undermine ethical leadership (35). In other words, personal attributes, previous experience, and also organizational rules will influence nurses’ attitudes (36). Thus, nurse leaders may face dilemmas when defining what is ethical and what is not, in addition to experiencing ethical distress when forced to make decisions against their ethical values (27, 35). As conflicts between their beliefs and institutional values can represent obstacles to ethical decision-making (27, 35), nursing leaders should regularly evaluate themselves and their attitudes (35). Ethical leadership seems more complicated in health institutions than in educational institutions, as many ethical dilemmas can arise in clinical environments (27).
4.3. Nursing Leadership Education
The importance of nursing leadership education to reduce mistakes, introduce a nursing leadership model, and improve competency was pointed out by nurse leaders (34). In addition, three of the included studies in this review analyzed students' views of nursing leadership (30-32). It was identified that nursing students might feel anxious due to a lack of management knowledge, but they also are eager to exercise leadership in the near future (30).
The importance of providing leadership training in the early years of nursing education was pointed out (30-32), as such training can make students learn about policies, regulations, and job descriptions (30), which develops their visions of the nursing profession (30, 32). A lack of knowledge of clinical nursing leadership was noticed in some students (32); the importance of clinical leadership to provide holistic care since it may fill gaps that still exist between theoretical and practical nursing education was emphasized (30, 31, 34). In addition, a lack of financial and institutional support was pointed out as an obstacle to nursing leadership education (34). Differences between generations were also reported as barriers to nursing leadership education because professors can seek pedagogical methods that are not interesting for students who currently get information from social media (34).
Studies highlighted that developing clinical nursing leadership projects involving educators and students (31), watching clinical nursing leadership videos, observing role models, and developing group discussions can be useful for students to learn clinical nursing leadership (32). Also, Evidence-based programs should be developed in undergraduate and postgraduate nursing courses, as the knowledge acquired through such methods is essential for future nursing leaders (33). Moreover, a study emphasized that individual and organizational leadership are fundamental for research to be carried out in nursing, which will ensure evidence-based care (36).
5. Discussion
This integrative review aimed to explore the scientific literature concerning different nursing leadership aspects. Through the studies included in this review, the impact of leadership on different functions of nurses, such as care, education, management, and research, was identified. The included studies mentioned the importance of leadership for nurses' job satisfaction and quality of care. The characteristics/skills of nursing leaders and the role of leaders as sources of motivation and inspiration for the nursing team were emphasized. Studies pointed out the importance of ethical nursing leadership, and the difficulties leaders may face in making ethical decisions. The need to teach leadership through practical and theoretical classes for undergraduate nursing students was also reported.
In the studies included in this review, commitment, competence, passion, and also skills such as problem-solving, interpersonal relationships, and empathetic communication were identified as necessary features for nursing leaders. In addition, nursing leaders were seen as mentors and monitors who should motivate other team members. The literature on leadership mentions different abilities, such as technical, conceptual, diagnostic, political, and human skills, when discussing the necessary characteristics of leaders. However, human skills such as understanding and motivating individuals and working and communicating with different groups seem to be the most necessary features for leaders (37). Nursing leadership refers to various aspects of the nursing routine and involves effective communication, coordination skills, and interaction with other health professionals, hospital administrators, and patients. Nurses organize, coordinate, and control their team and care process (38). Studies identified that communicative, good listeners, well-informed, and open individuals have more chances to succeed as leaders (39, 40). In a study conducted in 2020 with millennial nurses, leaders were identified as mentors, monitors, and coordinators who have important roles in nurses' job satisfaction and retention (41). It is difficult to determine how much nursing leadership can influence the care process, but it is known that nursing leaders need to create an appropriate work environment and empower their followers, and these factors bring positive consequences for care (4).
According to the studies selected for this review, nursing leaders are important for formulating policies and procedures that aim to guarantee the quality of care and, consequently, the success of health institutions. A study carried out in Spain (2013) pointed out the importance of developing leadership styles that lead to empowering nurses and improving the health system's efficiency and efficacy (42). Nurses play a critical role in formulating health policies at different administrative levels, ranging from the organizational level to higher health system levels. Nurses can use their leadership skills and attitudes to influence others and be essential in decision-making that will reflect on the population's well-being (43). In addition, nurse leaders' attitudes affect staff nurses' job satisfaction; thus, leadership styles influence healthcare quality indicators (44). A study conducted in the Philippines (2021) reported how toxic leadership could negatively affect the quality of care since it can lead to errors in drug administration and increase infection rates and patient falls (3).
Ethical nursing leadership and the difficulties nurses face while making ethical decisions in the clinical environment were emphasized in some of the studies included in this review. Ethics in nursing leadership is discussed in several studies (14, 45). According to a study carried out in Iran (2017), ethical leaders are sensitive to care, errors, communication, decision-making, and practice; thus, when adopting ethical leadership, nurses become role models to other health team members (14). A study conducted in Egypt (2021) also pointed out the importance of the ethical behavior of leaders to positively influence staff nurses (45). A study from Turkey (2019) identified the relationship between ethical leadership and nurses' job satisfaction (46). After the emergence of the COVID-19 pandemic, the interest in ethical nursing leadership became even more common (47-49). Nursing leadership must be conducted to support and empower nurses and protect patients (50). However, nurses face barriers that can make adopting an effective leadership style challenging. According to a systematic review, budget, team diversity, workload, lack of human resources, and policies related to patient safety are some of the challenges that may affect nursing leadership (51). In a study conducted in Norway (2022), nurse leaders stated that personnel matters are the most energy-intensive, as it is difficult to be fair and understanding when there are staff shortages and excessive workloads (52).
The importance of teaching leadership to nursing students so that they become competent nurse leaders was emphasized in this review. Nursing educators identify the importance of addressing leadership from the early years of undergraduate courses and that practical classes are essential in training nurse leaders (53). A study carried out in Brazil (2017) pointed to the importance of training nursing students in leadership and improving such knowledge through postgraduate courses and continuing education (54).
Different aspects of nursing leadership are widely discussed in the scientific literature. Leadership needs to be exercised in all dimensions of nursing, so nursing managers, frontline nurses, educators, and researchers must use their leadership skills in favor of quality care (18, 43). Nurses have important roles in the health system, so nursing leadership occupies a decisive place in the health sector. Nursing leaders must make fair decisions and be role models for their teams, as their attitudes affect the satisfaction of nurses and the quality of care. Ethical attitudes of nursing leaders are still important because they lead to inner satisfaction. Nevertheless, there are many barriers encountered by nurse leaders due to their characteristics and experiences, and also those of their followers. In addition, organizational policies and procedures can go against leaders' values, thus harming the decision-making process. The need to train nursing students to be fair and competent leaders is noteworthy. In addition, teaching leadership in health institutions through continuing education is an important measure to promote ethical nursing leadership.
An important limitation of this study is that the search was performed only on the titles of articles published in the last ten years. In addition, important databases were not searched, and relevant studies may not have been found due to the search criteria. However, the included studies enabled an important analysis of the importance of nursing leadership for care, management, teaching, and research.
5.1. Conclusions
Leadership is important in all roles performed by nurses. Nurse leaders influence other team members and patients; consequently, nursing leadership impacts the quality of care. Thus, nursing leadership is pivotal in creating a safe environment for nurses and patients. In the research area, individual and organizational leadership are important to provide data for evidence-based care.
Administrators of educational and health institutions must be attentive to nursing leadership, as training competent nurse leaders are important for providing quality care and, consequently, organizational success. Therefore, training on leadership should be addressed in nursing schools in undergraduate and postgraduate courses and health institutions through continuing education.
