research articles on nursing leadership

Leadership styles in nursing

Affiliation.

• 1 Murdoch University, Murdoch, Australia.
• PMID: 28635480
• DOI: 10.7748/ns.2017.e10836

Nurses are often asked to think about leadership, particularly in times of rapid change in healthcare, and where questions have been raised about whether leaders and managers have adequate insight into the requirements of care. This article discusses several leadership styles relevant to contemporary healthcare and nursing practice. Nurses who are aware of leadership styles may find this knowledge useful in maintaining a cohesive working environment. Leadership knowledge and skills can be improved through training, where, rather than having to undertake formal leadership roles without adequate preparation, nurses are able to learn, nurture, model and develop effective leadership behaviours, ultimately improving nursing staff retention and enhancing the delivery of safe and effective care.

Keywords: leadership; leadership skills; leadership styles; management; professional development; transactional leadership; transformational leadership.

• Open access
• Published: 24 April 2024

Disaster literacy in disaster emergency response: a national qualitative study among nurses

• Di Zhang 1 ,
• Li-Yan Zhang 1 , 2 ,
• Ke Zhang 3 ,
• Han Zhang 4 ,
• Huan-fang Zhang 5 &
• Kai Zhao 6  

BMC Nursing volume  23 , Article number:  267 ( 2024 ) Cite this article

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Metrics details

As the largest group of healthcare professionals, nurses play an indispensable and crucial role in disaster response. The enhancement of nurses’ disaster literacy is imperative for effective disaster emergency management. However, there is currently a lack of knowledge regarding nurses’ disaster literacy. This study represents the first attempt to explore the key components and characteristics of disaster literacy among nurses.

A qualitative descriptive design was employed, and the reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (refer to File S1). The purposive sampling method was utilized. Thirty-one rescue nurses from 31 medical institutions across 25 provinces and regions in China were recruited to participate in the study. The respondents were requested to share their experiences and insights regarding disaster rescue operations. Inductive content analysis was employed for data examination.

The results indicated that rescue nurses universally recognized that there was a pressing need to enhance the level of disaster literacy among nurses. The disaster literacy of nurses encompasses nine dimensions: physical and mental quality, disaster rescue general knowledge, professional and technical competence, professional ethics, teamwork, emotional ability, information literacy, leadership, and knowledge transformation.

Conclusions

To ensure national sustainability, government departments, healthcare organizations, and hospital administrators can accurately evaluate the disaster literacy of individual clinical nurses, groups, and the workforce as a whole through nine dimensions, which also can provide evidence to support the development of precision strategies to strengthen the disaster literacy of nurses.

Peer Review reports

Disaster prevention has long been a priority of the international healthcare system [ 1 ]. Effective disaster risk management is intricately intertwined with the attainment of the Global Sustainable Development Goals [ 2 ]. In 2020, for instance, the unforeseen proliferation of COVID-19 impeded global endeavors to accomplish the Sustainable Development Goals worldwide [ 3 ]. Nevertheless, this pandemic has also engendered an unparalleled surge in media and public attention towards nursing [ 4 ], along with a global discourse regarding the pivotal role played by nursing professionals in national disaster response and public safety.

Nurses are the largest group of healthcare professionals globally and serve as the primary responders during disaster rescue operations [ 5 ]. Enhancing disaster literacy within this extensive group can significantly enhance treatment efficiency, an aspect that is often overlooked [ 6 ]. Disasters frequently occur unexpectedly, resulting in chaotic and intricate environments at rescue sites, which starkly contrasts with structured clinical settings comprising fixed clinical departments and medical staff. Consequently, experienced or trained nurses are indispensable for managing the complexities associated with such situations. The demanding treatment environment characterized by inadequate resources, scarcity of supplies and medications, urgent tasks, and psychological stress places heightened demands on nurses engaged in disaster rescue efforts. According to the State of the World’s Nursing Report 2020, advancing disaster nursing disciplines will play a pivotal role in shaping the future of global nursing [ 7 ]. Consequently, adapting traditional first aid structures, nursing skills, and theoretical frameworks to suit disaster scenarios has proven challenging.

Despite this, not every nurse is adequately prepared to confront these situations. Studies have confirmed that nurses’ knowledge, skills, and abilities in disaster emergency response are insufficient to deal with such circumstances [ 8 – 9 ]. Furthermore, it should be noted that the concepts of knowledge, skill, ability, and literacy are distinct and cannot be equated. In the context of disaster rescue operations, saving lives is a crucial ability, life first is the value of faith, and dedication is the necessary character. The disaster rescue scene serves as a litmus test for nurses’ emergency response capabilities, however, possessing the necessary ability does not necessarily imply having literacy in this domain. According to the Organisation for Economic Co-operation and Development (OECD), literacy encompasses not only knowledge and skills but also the capacity to utilize psychosocial resources effectively in complex situations [ 10 ]. Literacy possesses multiple dimensions, extending beyond the mere acquisition of knowledge or skills, with a greater emphasis on their practical application for problem-solving during critical incidents. Consequently, disaster literacy aims at enhancing nurses’ disaster nursing abilities by integrating and promoting their knowledge and skills, processes and methods, emotional attitudes, as well as values [ 11 ]. The development of disaster literacy proves advantageous for nurses when confronted with diverse emergencies that arise from local conditions within a disaster scenario.

However, there is currently a lack of global studies examining the conceptual connotation of disaster literacy in professional groups, specifically focusing on nurses. Furthermore, existing research indicates that nurses may be inadequately prepared to effectively respond to disasters [ 12 – 13 ]. Therefore, it is imperative to discuss the significance of disaster literacy among nurses and elucidate the characteristics that nurses should possess.

The qualitative and descriptive design was used in this study to determine the disaster literacy characteristics that nurses should have from the perspective of rescue nurses. The present study employed a qualitative and descriptive design to ascertain the disaster literacy characteristics that nurses should possess from the perspective of rescue nurses. Utilizing a qualitative descriptive design is considered the most effective approach for directly gathering information from survey participants [ 14 ]. Qualitative descriptive research aims to provide comprehensive accounts of experiences in authentic settings using straightforward language, thereby enabling detailed descriptions of otherwise unknown occurrences [ 15 ]. Consequently, employing a qualitative descriptive study design ensures that data analysis remains faithful to participants’ descriptions and facilitates transparency in researchers’ judgments.

To ensure the interviews remain focused on the topic, this study developed an interview outline based on the STAR tool [ 16 ]. The STAR method is a commonly employed technique by interviewees to effectively respond to behavioral interview questions. STAR stands for Situation, Task, Action, and Result. Through utilizing the STAR method, interviewees articulate their job-related scenarios eloquently, describe their responses comprehensively, and provide detailed outcomes when addressing behavior-based inquiries. Thus, the utilization of the STAR method guarantees that interviewees are capable of delivering concise and persuasive answers. The formal interview outline is finalized after thorough review and modification by experts in the qualitative research field within the project team as presented in Table  1 .

Setting and participants

The purposive sampling method was employed to recruit participants. The selection criteria for participants are as follows: (1) Licensed registered nurses from medical and healthcare institutions nationwide; (2) Participation in at least two out of the four major disaster types, including natural disasters (earthquakes, floods, snowstorms, etc.), accident disaster (mining accidents, traffic accidents, accidents at public facilities and equipment, etc.), public health events (SARS, Avian Influenza, New Crown Pneumonia Pandemic, etc.), and social security events (mass incidents, terrorist attacks, emergencies affecting market stability, particularly significant foreign-related incidents, etc.); (3) Willingness to be interviewed. Recruitment and selection encompass China’s seven administrative geographic regions. The exclusion criteria are as follows: (1) Involvement in fewer than two disaster rescue events; (2) Incomplete provision of personal and disaster relief information during formal interviews leading to unanalyzable data; (3) Insufficient interview time available for the participant.

Data collection

The recruitment notice was disseminated to all provincial disaster nursing professional committees through the Disaster Nursing Professional Committee of the Chinese Nursing Association in this study. Rescue nurses who met the inclusion criteria were contacted via email or phone as stated in the recruitment notice, and they provided us with their personal contact information. Before conducting pre-interviews and formal interviews, we communicated with each individual by phone or email and sent them an informed consent form, which they signed and returned to our research team. The qualitative descriptive design was employed to collect individual interview data from July to September 2021. Due to the influence of epidemic prevention and control measures during that period, telephone interviews were conducted for this study. Before the formal interviews, two participants were selected by the interview team for pre-interviews to identify and address any issues that may arise during the interviews, ensuring their effectiveness. The formal interviews commenced by adhering to the interview outline and requirements. The researchers meticulously recorded each interview, capturing nuances such as tone of voice, intonation, pauses, etc., and appropriately labeling them. Each interview was transcribed verbatim upon initial recording. The duration of these interviews ranged from 30 to 77 min with an average of 47 min.

Data analysis

This report adheres to the EQUATOR Guidelines for Research Reporting as well as the Comprehensive Criteria for Reporting Qualitative Research (COREQ), which comprises a set of 32 items suitable for individual interviews [ 17 ] (refer to File S1). In China, data collection and analysis were conducted concurrently. The data underwent six steps of inductive content analysis [ 18 ]. Each step was meticulously validated by the researchers to ensure the quality and credibility of the analysis [ 19 ]. Two researchers listened to the recordings several times, independently analyzed the texts, and subsequently engaged in discussions until reaching a consensus.

We employed the qualitative research methodology developed by Graneheim et al. to enhance the credibility, reliability, verifiability, transferability, and authenticity of our study [ 20 ]. During the recruitment phase, we established inclusion and exclusion criteria to identify participants with extensive experience in disaster rescue operations and their ability to effectively articulate those experiences. Considering that content analysis emphasizes variations in content, diversity, and differences across different types of disasters, we conducted purposive sampling to recruit participants from various regions across the country for interviews. To develop an interview outline, we sought guidance from esteemed experts in disaster response and qualitative research. Before the interviews, researchers underwent comprehensive training in systematic qualitative research and content analysis to acquire relevant knowledge and refine their interviewing skills. In order to fine-tune the interview questions during the process and establish a clear framework for the formal interviews, two pre-interviews were conducted by the interview team. Text analysis was performed independently by two researchers, followed by extensive discussions until a consensus was reached [ 21 ]. Moreover, this study employed a six-step method of qualitative content analysis for category analysis to ensure credibility and authenticity [ 18 ]. Original recordings, transcripts, and coding memos from all participants were retained for auditing purposes as well as cross-verification. Additionally, adherence to the Comprehensive Criteria (COREQ) outlined in the report’s inventory of qualitative studies was strictly observed [ 17 ].

Ethics approval and consent to participate

This study is part of a larger research project, and all phases of this study have received approval from the Medical Ethics Committee of Jiangsu University. All participants were provided with information regarding the purpose of the study, and both verbal and written informed consent was obtained after emphasizing that participation was entirely voluntary. Additionally, all participants were notified about the strict confidentiality measures in place for their interview data. They had the option to withdraw from the study at any time, with the assurance that their interview data would be deleted. Furthermore, all data has been anonymized and de-identified, with restricted access limited to researchers only.

A total of 33 disaster nurses were recruited for interviews in this study, but one could not be reached and one was interviewed for less than 30 min. Consequently, we obtained 31 valid interview materials. Nurse codes were assigned from N1 to N31, using the first letter of each nurse’s name as their code number. Descriptive information for each participant is provided in Table  2 . The average age of the interviewed nurses was (38.45 ± 6.51) years old, with an average RN experience of (16.77 ± 7.50) years. On average, they had participated in disaster rescues (2.87 ± 0.92) times and belonged to a category of disaster rescue with an average rating of (1.87 ± 0.56). The interviews lasted on average for (47.23 ± 12.63) minutes. The demographics are listed in Table  3 .

All interviewed disaster rescue nurses unanimously agreed on the critical importance of studying disaster literacy in nursing and emphasized that government departments and healthcare institutions should promptly enhance education and training programs for nurses, including nursing students, to effectively respond to various potential disasters. Additionally, data from interviews were analyzed and summarized to extract nine essential characteristics of disaster literacy that nurses should possess, as presented in Table  4 .

Physical and mental quality

Most participants concurred that nurses must possess physical fitness and stamina to effectively carry out high-intensity rescue work in extreme environments at disaster sites. Nearly all participants agreed that nurses should have the ability to self-regulate and manage their emotions during the process of disaster response. Additionally, all participants emphasized the significance of nurses promptly recognizing and intervening when a patient or injured individual is undergoing a psychological crisis.

If your physical condition is not optimal, you may become a liability to the team when going out to rescue people. (N31). He suffered a head injury during the earthquake, but as an infant, he was remarkably adorable with plump white cheeks resembling a small meatball… Later on, despite leaving that ward I never wanted to enter again, whenever I think of his chubby figure lying uncomfortably on the hospital bed, it reminds me of the profound psychological impact caused by this experience. (N2).

Disaster rescue general knowledge

The majority of participants emphasized the importance for nurses to possess a comprehensive understanding of the characteristics, nature, and specific circumstances associated with different types of disaster events. Additionally, they should be equipped with general knowledge to effectively safeguard their safety as well as that of others at the disaster site.

After undergoing nearly two months of intensive training, primarily focused on epidemic prevention, isolation protocols, disease nursing techniques, and cultural sensitivities in Africa, as well as language instruction, we must acquire a comprehensive understanding of the highly contagious nature of Ebola before we can effectively assist. (N25). The lack of preparedness was evident during our rescue mission, encompassing ourselves, the supplies we brought, and a significant portion of our management, personnel, and materials. This remains a regrettable oversight. (N20).

Professional and technical competence

The participants unanimously emphasized the importance for nurses to possess a comprehensive understanding of theoretical knowledge in the field of nursing, proficient skills in hospital emergency nursing procedures, and fundamental abilities in on-site rescue nursing before engaging in rescue operations. Additionally, they stressed the necessity for nurses to be well-versed in common pre-hospital emergency nursing knowledge.

…. Subsequently, her blood pressure and vital signs exhibited a decline, necessitating an accelerated administration of fluids while adjusting the patient’s position to manage shock. I am grateful for the invaluable experience gained during my rotation in anesthesiology, particularly in mastering intubation techniques… (N28). When transferring patients, our medical staff should possess not only exceptional professional skills but also a profound understanding of the characteristics of disaster rescue and potential accidents. (N30).

Professional ethics

The majority of participants emphasized the importance for nurses to possess political acumen and maintain strict confidentiality during rescue operations. Additionally, they highlighted the significance of professional dedication, subjective initiative, prioritizing life above all else, and a strong sense of responsibility. Moreover, nurses need to comprehend and apply the utilitarian principle in their ethical practice.

Considering the potential hazards present at disaster sites, it is imperative to foster a spirit of sacrifice. It is crucial to harness the selfless dedication instilled in us during our medical education. For instance, during a pandemic like COVID-19, one must be willing to make personal sacrifices for survival. (N3). The addition I propose is the cultivation of awe, a reverence for life, and unwavering faith. The fundamental purpose of studying medicine should remain unchanged - prioritizing the patient’s well-being and valuing human life above all else. This mindset is crucial as it embodies the spirit of selfless dedication. (N23).

The overwhelming majority of participants emphasized the paramount importance of nurses possessing a robust capacity for medical/nursing collaboration, as well as adeptness in multi-/cross-disciplinary or sectoral integration within rescue scenarios.

The second point is that in the event of an emergency, it is crucial to promptly assemble a highly proficient medical team. (N17). The field of rescue operations necessitates not only intra-unit collaboration but also inter-unit cooperation, thereby demanding specific interdisciplinary collaborative skills. (N24).

Emotional ability

The consensus among all participants was that nurses should possess the ability to effectively communicate with both disaster victims and rescue workers, particularly through perspective-taking and empathy. Furthermore, they should be capable of providing humanistic care during disaster rescue operations.

Communication with disaster victims is also crucial as it plays a vital role in alleviating their fears and facilitating their acceptance of treatment, thus promoting cooperation during the treatment process. (N25). Many patients are experiencing extreme fear and anxiety due to their lack of knowledge about the novel coronavirus, leading them to believe that mere contact with it will result in death. While some patients remain silent, others display visible signs of concern… It is crucial to address the emotional distress experienced by different patients and employ empathy as a means to alleviate their negative emotions. (N9).

Information literacy

The majority of participants emphasized the importance for nurses to possess updated knowledge of rescue resources, emergency plans, policies, and procedures. Additionally, they should be proficient in promptly communicating/reporting priority disaster-related information to superiors or designated personnel at the disaster site and efficiently implementing it. Moreover, fluency in multiple languages is essential for effective communication with both disaster victims and rescue workers. Furthermore, collaboration with disaster leadership teams to develop media information on disaster events is also crucial.

The initial step we took was to break through the English language barrier by identifying and familiarizing ourselves with frequently used sentences and keywords in our processing. Subsequently, we engaged in effective communication with their leaders and translators. (N13). Many departments will request information, including the municipal government, the Health and Construction Commission, the emergency office, and some leaders in charge. How should this information be saved? Who has access to this information? We’d been… I was completely perplexed when I arrived on the scene. (N4).

The majority of participants emphasized the necessity for nurses to possess the ability to contribute to the organization of disaster emergency plans or the development of on-site work processes, as well as demonstrate proficient organizational coordination and management skills while assisting in safeguarding vulnerable populations.

The individual should exhibit decisiveness, demonstrate effective leadership skills, possess contingency planning abilities, and discern between right and wrong actions while articulating the rationale behind choosing the correct course of action. (N9). I believe it is crucial to adopt a disaster management mindset.… There should be an enhancement in the thinking and capabilities related to managing sudden major incidents. (N19).

Knowledge transformation

The significance of nurses’ ability to effectively respond to disasters and integrate disaster information into decision-making was unanimously emphasized by all participants. Concurrently, disaster health education, training, and scientific research can be conducted both during and after the occurrence of a disaster.

As a disaster rescue worker, it is essential to possess adaptability in response to unforeseeable circumstances. This entails the ability to modify work procedures and status based on real-time changes. (N25). Unfortunately, we don’t have a lot of time to research the front lines, which is something that must be done. (N11).

The findings of this study revealed that all participants provided positive feedback regarding the implementation of the disaster literacy study for nurses, as evidenced by the analysis of interview results. They urgently call upon relevant authorities, such as government bodies or healthcare organizations, to prioritize disaster literacy education and training for nurses. Furthermore, through feedback analysis, nine essential characteristics of disaster literacy that nurses should possess have been identified. To our knowledge, this is the first study to establish a comprehensive definition of disaster literacy specifically tailored for nurses. Consequently, it proposed a specific connotation of nurses’ disaster literacy based on their practical rescue experience and significantly contributes to the theoretical development framework within the field of disaster response.

The STAR path was employed in this study to facilitate one-on-one interviews, addressing the time constraints faced by nurses and enabling them to gather data effectively. This approach aided in refining the interview format, guiding participants’ attention toward event details, and encouraging reflection on specific experiences of interest. Thus, interviewers were able to delve into theories and establish characteristic indicators during the interviewing process. As a result, it is recommended that this methodology be widely adopted in future qualitative research endeavors.

The findings of this study are consistent with previous research [ 6 , 22 , 23 , 24 ], which indicates that nurses should prioritize their attention on dimensions such as physical and mental well-being, professional and technical competence, teamwork skills, and emotional resilience in disaster literacy. The majority of the participants in this study reported experiencing chaotic conditions at the disaster scene, encountering challenging tasks, being in suboptimal physical condition, and often being unable to complete rescue missions. Certain natural disasters and accidents tend to occur in harsh environments or regions. Nurses working in high-stress environments must possess robust emotional intelligence, adaptability to dynamic situations, and strong collaborative skills for effective task completion during extreme circumstances. Participants generally agreed that nurses should be capable of psychological and emotional adjustment throughout the process of disaster rescue, while also providing psychological counseling and emotional support to both victims and rescue personnel. As a result, effective psychological first-aid training is critical [ 25 – 26 ]. According to a recent systematic review, cognitive behavioral therapy, psychoeducation, or meditation may assist nurses in overcoming their lack of emotional preparedness [ 27 ]. Furthermore, professional preparedness is essential for effective disaster response. Existing research, however, indicates that nurses are not fully prepared for a disaster emergency [ 28 ]. According to studies, themed game-based training is more effective than traditional scenario simulation and case teaching in improving nurses’ disaster response-ability [ 29 – 30 ]. As a result, managers should establish corresponding disaster training programs to enhance nurses’ disaster literacy.

Another significant finding of this study is that disaster rescue general knowledge, professional ethics, and information literacy are considered crucial dimensions of nurses’ disaster literacy. This aspect has been rarely reported in previous studies, thereby enhancing the development framework of disaster rescue disciplines. Because disaster events occur unexpectedly, nurses must respond effectively and quickly, so nurses must understand the various types and characteristics of disasters. Acquiring such rescue general knowledge will enable nurses to enhance their self-awareness regarding disasters and facilitate quicker and more efficient responses [ 31 ]. Participants in this study emphasized that nurses involved in disaster rescue should possess not only initiative and professionalism but also a profound professional conviction regarding the value of life and a genuine passion for nursing work. This ensures that nurses are willing to provide essential care during such catastrophic events. Moreover, it is crucial to address the severe global nurse shortage [ 32 ], inadequate nursing manpower, and inefficient disaster response systems [ 33 ]. Previous research has demonstrated that organizational support plays a pivotal role in enhancing nurses’ engagement and reinforcing their professional beliefs [ 34 ]. As a result, managers should utilize this data to enhance disaster management policies, increase nursing manpower, and encourage more nurses to volunteer for disaster rescue work. It is worth noting that some study participants mentioned that nurses should have important qualities such as timely follow-up on disaster information, timely reporting of priority information at the disaster site, and if permitted, joint development of media information with managers. Although rarely discussed, these aspects will be the focal point of future research on disaster nursing.

According to this study, enhancing leadership and knowledge transfer skills serves as a crucial indicator of nurses’ disaster literacy, which is reflected in organizational coordination, developing procedures or processes, safeguarding vulnerable groups, critical thinking, integrating information, health education, and scientific research. A disaster is defined as an occurrence that disrupts the normal functioning of a community and requires the utilization of external human and/or material resources for assistance [ 35 ]. Currently, the role of nurses in disaster rescue is not widely debated. Previous studies conducted by Chinese scholars have underscored that nurses’ involvement in disaster emergencies goes beyond being mere clinical nursing providers and encompasses crucial responsibilities such as coordination, problem-solving, and education [ 36 ]. This study confirms these findings. Disaster nursing significantly differs from clinical nursing as it necessitates nurses to handle a myriad of complex emergencies based on local circumstances. As a result, it is critical to strengthen the training of nurses’ transformational learning through daily disaster education and training, which will also be a focal point for future development in the field of disaster nursing discipline and the cultivation of nurses’ disaster literacy.

Limitations

The study was conducted within the same country. The qualitative approach could reflect the picture of disaster literacy from the Chinese context. However, it is important to note that certain in-depth information may only be applicable in specific contexts due to variations in the frequency and magnitude of different types of disasters. Furthermore, given that this study took place during the COVID-19 pandemic in China, caution should be exercised when generalizing the results across all phases of disasters.

This study identifies nine dimensions of disaster literacy that nurses should possess from the perspective of disaster rescue nurses. Including Physical and mental quality, Disaster rescue general knowledge, Professional and technical competence, Professional ethics, Teamwork, Emotional ability, Information literacy, Leadership, and Knowledge transformation. Disaster literacy research and practice among nurses must be promoted urgently by government agencies and medical institutions. Managers can utilize this feedback to enhance disaster management policies and provide continuous support for nursing professionals in their disaster response efforts through education, training, and effective management.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article [and/or its supplementary materials]. All data included in this study are also available by contact with the corresponding author.

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Acknowledgements

We thank all the study participants and their healthcare organizations, and the experts of the Disaster Nursing Professional Committee of the Chinese Nursing Association for their academic support.

This study was supported by Humanity and Social Science Youth Foundation of Ministry of Education of China (21YJC840036), Chinese Association of Degree and Graduate Education Project (2020MSA101), Social Science Foundation Project of Jiangsu Province (23JYD011), 2023 Jiangsu Province Higher Education Teaching Reform Research Projects(2023JSJG257), General Program of Humanities and Social Sciences of Soochow University (23XM1004).

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ZD and ZLY designed the current study. ZD, ZK, and ZH collected and analyzed the data. ZD and ZHF wrote the first manuscript, and ZK revised the manuscript. All authors read and approved the final manuscript for submission.

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This study is part of a larger research project., and all phases of this study have received approval from the Medical Ethics Committee of Jiangsu University. All participants were informed of the study’s purpose, and both verbal and written informed consent was obtained after it was emphasized that participation was completely voluntary. Furthermore, all participants were informed that the interview data would be kept strictly confidential. They had the option to withdraw from the study at any time, with their interview data being promptly deleted. Furthermore, all data has been anonymized and de-identified, with exclusive access granted solely to researchers.

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Zhang, D., Zhang, LY., Zhang, K. et al. Disaster literacy in disaster emergency response: a national qualitative study among nurses. BMC Nurs 23 , 267 (2024). https://doi.org/10.1186/s12912-024-01911-2

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Women and Mental Health in Education and Leadership

Work-life integration among nurse educators: A meta-synthesis Provisionally Accepted

• 1 University of Johannesburg, South Africa

The final, formatted version of the article will be published soon.

Background: Work-life integration has been extensively researched in various contexts.Women dominate the nursing profession, but work-life integration is essential for men and women since both are expected to focus equally on their families and careers. The nursing faculty perceives nurse educators' work environment as undervalued, lacking support, and limited time to grow and carry the heavy workload.Method: A qualitative meta-synthesis of studies between 2013 and 2023 was conducted using ScienceDirect, EBSCO Host, Sage and Sabinet databases. Seven articles related to the research phenomenon were retrieved.The resulting themes revolved around two central aspects: nurse educators' work and life integration. Nurse educators face various challenges with work-life integration and often view their failure as a personal rather than a societal issue. However, as much as achieving work-life integration is personal, there is a call for employers in academic environments to improve workplace policies, like better-paid maternity leave, affordable quality childcare, and social support. Furthermore, nurse educators' line managers should display warmth and encouragement about personal challenges affecting nurse educators.

Keywords: work-life balance, Nurse educator, Systematic review, Faculty (MeSH), nurse academic

Received: 01 Sep 2023; Accepted: 25 Apr 2024.

Copyright: © 2024 Erasmus, Downing and Ntshingila. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Prof. Charlene Downing, University of Johannesburg, Johannesburg, 2092, Gauteng, South Africa

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A systematic review of the relationships between nurse leaders' leadership styles and nurses' work‐related well‐being

Milja niinihuhta.

1 University of Eastern Finland, Finland

Arja Häggman‐Laitila

2 Social and Health Care, City of Helsinki, Helsinki Finland

Associated Data

The data that supports the findings of this study are available in the supplementary material of this article

This systematic review aimed to summarize current research knowledge about the relationships between nurse leaders' leadership styles and nurses' work‐related well‐being.

Due to the global shortage of nurses, it is essential for nurse leaders to maximize staff retention and work‐related well‐being.

Following Cochrane Collaboration procedures, the PRISMA statement and PRISMA checklist, relevant quantitative studies published between 1 January 2012 and 31 December 2020 were retrieved from the CINAHL, Scopus, PubMed and Medic databases and then systematically reviewed. Seventeen cross‐sectional and follow‐up studies with surveys were retained for inclusion and evaluated with the Critical Appraisal of a Survey instrument. The data were summarized narratively.

Three core themes of leadership styles: destructive, supportive and relationally focused, were identified, with statistically significant direct and indirect connections between nurses' work‐related well‐being. Well‐being was mainly assessed in terms of burnout. Effects of leadership styles on work‐related well‐being were reportedly mediated by trust in leader, trust in organization, empowerment, work‐life conflict, relational social capital, emotional exhaustion, affectivity, job satisfaction and motivation.

Nurse leaders' leadership styles affect nurses' work‐related well‐being. In developing intervention studies and providing training on work‐related well‐being, the impact of the indirect effects and the mediating factors of the leadership styles should be acknowledged.

Summary statement

What is already known about this topic?

• Nurse leaders play a key role in maximizing staff retention and influencing healthcare organizations' productivity and effectiveness.
• Nurse leaders' leadership styles strongly affect the nursing staff, their working environment and work‐related well‐being.

What this paper adds?

• This systematic review shows that nurse leaders' destructive, supportive and relationally focused leadership styles significantly affect nurses' work‐related well‐being.
• It provides detailed information regarding direct and indirect associations between leadership styles and work‐related well‐being and the mediating variables for indirect associations.
• The data suggest that nurse leaders should be capable of using supportive and relationally focused leadership styles.

The implications of this paper

• Systematic evaluation of nurse leaders' leadership styles in organizations is important because they significantly affect nurses' work‐related well‐being.
• Results of this review could be used when developing nurse leaders' leadership styles and work environments and planning and implementing leadership training.
• In the developing of intervention studies on work‐related well‐being, the results of the indirect effects and the mediating factors of the leadership styles should be acknowledged.

1. INTRODUCTION

The worldwide shortage of nurses (Chan et al.,  2013 ; Heinen et al.,  2013 ; WHO,  2016 ) poses a major challenge for leadership in nursing. Nurses who stay in their profession, work efficiently and produce good patient outcomes, have also generally high work‐related well‐being (Long,  2020 ; Nantsupawat et al.,  2016 ; Van Bogaert et al.,  2014 ). Several reviews (Cummings et al.,  2018 ; Skakon et al.,  2010 ; Weberg,  2010 ) rooted in different disciplines have found that managers' use of certain leadership styles can enhance relationships with employees, performance, productivity, the working environment and work‐related well‐being. Conversely, inappropriate leadership increases costs, employee turnover and absenteeism while reducing performance.

Leaders' well‐being affects that of their subordinates (Skakon et al.,  2010 ). However, previous reviews (Awa et al.,  2010 ; Häggman‐Laitila & Romppanen,  2017 ; Romppanen & Häggman‐Laitila,  2017 ; Van Wyk & Pillay‐Van Wyk,  2010 ; Westermann et al.,  2014 ) indicate that this relationship is poorly studied. Most interventions targeting nurses' and nurse leaders' work‐related well‐being are focused on individuals' cognitive and behavioural skills. The most intensively studied aspects are burnout and stress management, although well‐being is widely understood in broader terms. According to a review by Buffer et al. ( 2013 ), work‐related well‐being is a comprehensive concept, which includes (besides occupational health and health behaviour), social and economic well‐being and well‐being connected to professional development, as well as both psychological and physical health. Moreover, each of these aspects are multidimensional. For example, psychological well‐being encompasses self‐esteem, autonomy, personal growth, sense of purpose in life, social support and mastery of environment (Jacobs et al.,  2013 ).

As nurse leaders play key roles in staff retention and both the productivity and effectiveness of healthcare organizations, their performance should clearly be developed using evidence‐based knowledge. Four previous reviews (Adams et al.,  2019 ; Cummings et al.,  2018 ; Long,  2020 ; Weberg,  2010 ) have examined effects of nurse leaders' different leadership styles on the nursing staff, their working environment and work‐related well‐being. Long's ( 2020 ) review of authentic leadership style showed that authentic leaders can promote newly qualified nurses' work‐related well‐being and retention. Adams et al. ( 2019 ) focused on the relationship between nurse managers' role and the well‐being of ICU nurses and found that nurse managers' behaviours affected the well‐being of their subordinates, through for example supportive behaviour, trust and inclusion in decision‐making.

Although these reviews provided valuable insights, systematic reviews are needed to identify leadership styles that maximize nurses' work‐related well‐being and to provide recommendations based on the latest and best research evidence. Such recommendations are needed to support the development of organizational practices and effective healthcare environments and policy. Thus, this article presents a systematic review concentrating exclusively on nurse leaders' leadership styles and nurses' work‐related well‐being. The aim was to summarize empirical research on the relationships between them by addressing three research questions: ‘Which leadership styles adopted by nurse leaders have been studied in connection with nurses' work‐related well‐being?’, ‘How was work‐related well‐being measured in those studies?’ and ‘How did the studied leadership styles reportedly affect nurses' work‐related well‐being?’

2.1. Design

This systematic review of quantitative studies was designed and implemented in accordance with Cochrane Collaboration protocols (Higgins & Green,  2011 ) and the PRISMA statement (Moher et al.,  2009 , Figure  1 ).

PRISMA flowchart

2.2. Search strategy and inclusion criteria

The CINAHL, Medic, SCOPUS and PubMed databases were systematically searched for relevant studies. The search strategies and terms were tailored to each database individually with guidance from a library‐based information specialist. Searches were performed by combining search terms using the Boolean operators AND, OR and NOT. Searches were limited to peer‐reviewed articles in English or Finnish languages published between 1.1.2012 and 31.12.2020 to obtain an updated view to the research topic and to avoid overlapping results with the previous review (Cummings et al.,  2018 ) (Table  1 ). The inclusion criteria were quantitative studies with experimental, quasi‐experimental or descriptive designs on the relationships between nurses' work‐related well‐being and the support, leadership skills, or leadership style of nurse leaders.

Search terms

2.3. Search outcome and exclusion criteria

The search yielded 4408 hits: 1048, 2072, 1277 and 11 from the PubMed, CINAHL, SCOPUS and Medic databases, respectively. After removing duplicates (362), 4046 articles remained for title and abstract review, which was performed by two researchers (Figure  1 ).

Articles retrieved based on abstracts were excluded from further analysis, if they were not written in English or Finnish and/or irrelevant to the research questions. Reviews, editorials and discussion papers were also excluded. After this exclusion process, 90 articles remained for consideration. Two researchers read the full texts of these articles to evaluate their eligibility for the review, resulting in the exclusion of a further 77 articles. Articles were also excluded after examination of the full texts if they did not address the research questions, were not research articles, could not be retrieved, addressed employees other than nurses or multiple professions, but the findings were not separated by professions, or previously retrieved articles reported the same results. Researchers screened every article independently. The disagreements between the researchers were solved through consensus discussions. The third opinion was not needed. The 13 articles remaining after this process were selected for inclusion, and their references were manually screened by two researchers to identify additional relevant articles. As a result, four further articles were included in the review (Figure  1 ).

2.4. Quality assessment

The final data consisted of 13 cross‐sectional and 4 follow‐up studies with surveys. They were assessed by two researchers with the checklist, Critical Appraisal of a Survey, developed for the survey studies (Center for Evidence‐based Management,  2014 ). It included 12 criteria (Table  2 ). The checklist did not include any guidance regarding rating the quality of the studies; therefore, the authors decided together the scale of ranking (Baatiema et al.,  2017 ; Bahadori et al.,  2020 ; Protogerou & Hagger,  2019 ). The researchers decided that if the study met over half of the criteria (7/12), it was accepted for the review. The quality was appraised satisfactory if the study met 7 or 8 of 12 criteria, and good if it met over 75% of the criteria (9 or 10/12). The quality of three studies was deemed satisfactory and others ( n  = 14) had good quality. All the studies that were included in the review addressed clearly focused questions using appropriate research methods, and the method used to choose subjects was described clearly. All the studies used representative samples and trustworthy measurement instruments. Satisfactory response rates were obtained in 14 of the studies, and the statistical significance of the results was assessed in all of them. However, confidence intervals were not reported in 11 of the articles, the minimum required sample size was only determined by preliminary statistical power analysis in six of the studies, and 16 of the articles did not address the possibility of confounding factors. All studies yielded results that were applicable to the authors' organization (Table  2 ).

Critical appraisal questions for the survey

2.5. Data extraction and analysis

Specifying information of the publication, the purpose of the study, study subjects, study context, methodology and statistically significant outcomes reported in each included article were extracted to the matrix and are listed in Table  3 . The articles were analysed by narrative synthesis (Popay et al.,  2006 ; Ryan,  2013 ). First, each article was read through once to form an overview of its content. They were then read repeatedly to obtain deeper insight into their content. Descriptions of all identified leadership styles were reduced into codes by both researchers independently. These codes were compared, checked and completed together to reach all the essential expressions from the data. The codes were compared according to their similarities and differences. Similar expressions were grouped under the same theme and the themes were named according to associated content. For example, in the study by Majeed and Fatima ( 2020 ) the exploitative leadership style was described as ‘egoistic behaviour, manipulation and pressurizing’. This code was grouped under the theme ‘nurse leaders’ selfishness and nurses' bad treatment’ and categorized under the core theme ‘destructive’. Altogether three core themes were identified (destructive, supportive and relationally focused leadership styles). Then the measurements of work‐related well‐being and reported relationships (direct and indirect) between leadership styles and work‐related well‐being were examined. Due to the heterogeneity of the leadership styles and measurements of work‐related well‐being, further synthesis such as meta‐analyses of the data was not possible (Higgins & Green,  2011 ).

Overview of the selected articles

3.1. Characteristics of the studies

The studies ( N  = 17) were conducted in eight countries: Italy ( n  = 2), Canada ( n  = 7), Iran ( n  = 3), Australia ( n  = 1), Pakistan ( n  = 1), Ireland ( n  = 1), Lebanon ( n  = 1) and Denmark ( n  = 1). The studies were cross‐sectional and longitudinal follow‐up surveys. Collectively, they described 12 leadership styles. In total, 11 instruments were used in them to measure work‐related well‐being. The number of participants per study ranged from 89 to 1617 and included: non‐graduated, newly graduated and experienced nurses; healthcare assistants; midwifes; and other health professionals such as physiotherapists or non‐healthcare personnel (e.g. cleaning staff). Participants worked in elderly care facilities and acute or critical care, in public, private and non‐profit maternity or governmental hospitals (Table  3 ).

3.2. Destructive leadership styles and nurses' work‐related well‐being

Five studies described destructive leadership styles, such as management‐by‐exception (Sabbah et al.,  2020 ), passive/avoidant including laissez‐faire (Ebrahimzade et al.,  2015 ; Pishgooie et al.,  2018 ; Sabbah et al.,  2020 ; Trepanier et al.,  2019 ), exploitative (Majeed & Fatima,  2020 ) and tyrannical (Trepanier et al.,  2019 ) styles (Table  4 ). Common described theme of these styles were nurse leaders' selfishness and nurses' bad treatment. Leaders with laissez‐faire leadership styles relied without justification on their employees' decision‐making skills and provided them too much autonomy. They avoided decision‐making and ignored leader's responsibilities (Ebrahimzade et al.,  2015 ; Pishgooie et al.,  2018 ). Characteristic features of exploitative leadership included egoistic behaviour, manipulation, belittling and pressuring employees (Majeed & Fatima,  2020 ). Tyrannical leaders lessened, downplayed and diminished their subordinates, often had unreasonable expectations and tended to meet goals of the organization at the cost of their employees' well‐being (Trepanier et al.,  2019 ).

The statistically significant associations between leadership styles and work‐related well‐being

Associations of these destructive leadership styles with work‐related well‐being were measured by five scales: the Maslach Burnout Inventory General Survey (MBI‐GS) in two studies (Ebrahimzade et al.,  2015 ; Trepanier et al.,  2019 ), the Health and Safety Executive Questionnaire (HSE) by Pishgooie et al. ( 2018 ), the SF‐12v2 Health Survey by Sabbah et al. ( 2020 ) and scales developed by Kessler et al. and Sonnentag and Fritz in the study by Majeed and Fatima ( 2020 ).

Laissez‐faire leadership was found to have a direct significant negative relationship with personal accomplishment by Ebrahimzade et al. ( 2015 ), a positive significant correlation with job stress by Pishgooie et al. ( 2018 ), and a direct significant association with burnout by Trepanier et al. ( 2019 ). Passive/avoidant leadership styles negatively correlated with mental health according to Sabbah et al. ( 2020 ). Exploitative leadership style had both direct and indirect (through increases in negative affectivity) effects on employees' psychological distress, according to Majeed and Fatima ( 2020 ). Trepanier et al. ( 2019 ) also found that tyrannical leadership indirectly affected nurses' burnout through controlled motivation (Trepanier et al.,  2019 ) (Table  4 ).

3.3. Supportive leadership styles and nurses' work‐related well‐being

Six studies described supportive leadership styles, such as supportive (Rodwell & Munro,  2013 ), transactional (Ebrahimzade et al.,  2015 ; Pishgooie et al.,  2018 ; Sabbah et al.,  2020 ), empowering (Bobbio et al.,  2012 ) and resonant (Laschinger et al.,  2014 ). Common recognized themes of these leadership styles were faith in employees' resources, organizational procedures targeting to enhance employees' capacities, desire to utilize resources fully in prevailing circumstances and acting as an example. Transactional leaders were described as task‐oriented and to emphasize the roles of employees. They were said to concentrate on their relationships with their employees and promote interactions by building commitment to the organization. They encouraged employees by implementing performance‐based reward systems with penalties for deviating from standard action (Ebrahimzade et al.,  2015 ; Pishgooie et al.,  2018 ; Sabbah et al.,  2020 ). Besides this, empowering and resonant leaders lead by example. They were described as participative in their decision‐making. They coached, encouraged and informed their employees and showed them concern. They took account of the current situation, human resources, emotions and the surroundings (Bobbio et al.,  2012 ; Laschinger et al.,  2014 ).

These supportive leadership styles' associations with work‐related well‐being were measured by four instruments: the MBI‐GS in three studies (Bobbio et al.,  2012 ; Ebrahimzade et al.,  2015 ; Laschinger et al.,  2014 ), the HSE by Pishgooie et al. ( 2018 ), the General Health Questionnaire (GHQ) by Rodwell and Munro ( 2013 ) and the SF‐12v2 by Sabbah et al. ( 2020 ). Supervisor support significantly and directly predicted nurses' well‐being according to Rodwell and Munro ( 2013 ). Transactional leadership had a direct significant negative relationship with burnout, including emotional exhaustion and depersonalization (Ebrahimzade et al.,  2015 ), and significant negative correlation with job stress (Pishgooie et al.,  2018 ). Empowering leadership had strong positive effects on trust in both the leader and organization, and they mediated negative correlations of empowering leadership with elements of job burnout, specifically emotional exhaustion and cynicism (Bobbio et al.,  2012 ). According to Laschinger et al. ( 2014 ), resonant leadership style had a strong positive direct influence on empowerment and thereby reduced incivility and emotional exhaustion (Table  4 ).

3.4. Relationally focused leadership styles and nurses' work‐related well‐being

In total, 12 studies described relationally focused leadership styles, such as transformational (Ebrahimzade et al.,  2015 ; Munir et al.,  2012 ; Pishgooie et al.,  2018 ; Sabbah et al.,  2020 ), authentic (Laschinger et al.,  2013 , 2015 ; Laschinger & Fida,  2014 ; Nelson et al.,  2014 ; Read & Laschinger,  2015 ), servant (Bobbio & Manganelli,  2015 ) and ethical (Kaffashpoor & Sadeghian,  2020 ; McKenna & Jeske,  2021 ). These leadership styles differed from the leadership styles that we named supportive by the characteristics of the leader employee relationship and by the way leaders enhanced the growth of their employees and motivated them to involve in decision‐making. Common identified themes of the relationally focused leadership styles included desire to form an equal and reciprocal relationship with employees, challenging employees to participate and value‐driven behaviour. For example, transformational leaders were described as being visionary, intellectually stimulating and applying innovative methods to motivate their followers in problem‐solving. They successfully coached groups to achieve their goals, encouraged their employees to participate, and inspired their self‐confidence by giving them responsibilities and considering their personal differences (Ebrahimzade et al.,  2015 ; Munir et al.,  2012 ; Pishgooie et al.,  2018 ; Sabbah et al.,  2020 ). Ethical, authentic and servant leaders allowed employees to participate in decision‐making, clarified expectations, communicated openly and clearly, and encouraged them to flourish and learn from mistakes. They requested insights from employees before making important decisions and were described as honest, caring, fair, accountable, trustworthy and principled. They were aware of their own strengths and weaknesses, and personally integrated. (Bobbio & Manganelli,  2015 ; Kaffashpoor & Sadeghian,  2020 ; Laschinger et al.,  2013 ; Laschinger & Fida,  2014 ; Laschinger et al.,  2015 ; McKenna & Jeske,  2021 ; Read & Laschinger,  2015 ).

In the studies on relationally focused leadership styles work‐related well‐being was measured using eight instruments: the MBI‐GS in six studies (Bobbio & Manganelli,  2015 ; Ebrahimzade et al.,  2015 ; Laschinger et al.,  2013 , 2015 ; Laschinger & Fida,  2014 ; McKenna & Jeske,  2021 ) and the Mental Health Index (MHI‐5) in two studies (Laschinger & Fida,  2014 ; Read & Laschinger,  2015 ). The HSE was used by Pishgooie et al. ( 2018 ), a 5‐item psychological well‐being scale by Munir et al. ( 2012 ), and a four subjective well‐being item scale by Kaffashpoor and Sadeghian ( 2020 ). In addition to these, the relationally focused leadership styles were measured by the Psychological Capital Questionnaire (Laschinger & Fida,  2014 ), the SF‐12v2 (Sabbah et al.,  2020 ) and the Psychological Well‐being at Work scale, adapted from a scale by Masse et al. (Nelson et al.,  2014 ). Transformational, ethical, servant and authentic leadership styles were found to have direct associations with work‐related well‐being. Transformational leadership reportedly had statistically significant direct negative relationships with burnout symptoms, including emotional exhaustion and depersonalization (Ebrahimzade et al.,  2015 ) and a negative correlation with job stress (Pishgooie et al.,  2018 ). Authentic leadership had a direct effect on psychological well‐being according to Nelson et al. ( 2014 ) and a small negative impact on cynicism (Laschinger et al.,  2013 ), whereas ethical leadership had been found to have direct effects on subjective wellbeing (Kaffashpoor & Sadeghian,  2020 ) and emotional exhaustion (McKenna & Jeske,  2021 ) (Table  4 ).

In addition to direct associations with work‐related well‐being, transformational, authentic and ethical leadership styles also reportedly had indirect associations. Work‐life conflict mediated connections between transformational leadership and psychological well‐being (Munir et al.,  2012 ). Empowerment (Laschinger et al.,  2013 ) and work climate (Nelson et al.,  2014 ) mediated connections between authentic leadership and psychological well‐being, including lower emotional exhaustion and cynicism, whereas job satisfaction was a mediator of effects of ethical leadership on subjective well‐being (Kaffashpoor & Sadeghian,  2020 ). Recorded mediators of authentic leadership effects included emotional exhaustion on mental health problems (Laschinger & Fida,  2014 ), work life on burnout and mental health (Laschinger et al.,  2015 ) and relational social capital via structural empowerment on mental health symptoms (Read & Laschinger,  2015 ). Bobbio and Manganelli ( 2015 ) found that trust in the leader mediated significant standardized indirect effects of servant leadership in three burnout dimensions. Finally, McKenna and Jeske ( 2021 ) found that the mediator of ethical leadership effect on emotional exhaustion was decision authority (Table  4 ).

4. DISCUSSION

4.1. consideration of results.

This systematic review of quantitative studies showed that nurse leaders' leadership styles significantly affected nurses' work‐related well‐being. The results were consistent although the studies had been carried out in eight culturally diverse countries. The articles included in the review described 12 leadership styles, and 11 instruments designed to measure elements of work‐related well‐being. The diversity of instruments highlights the complexity of the concept of work‐related well‐being. The most frequently studied leadership styles were relationally focused styles: transformational, authentic, ethical and servant, all of which were found to be positively associated with nurses' work‐related well‐being. Our review also included 11 studies that Cummings et al. ( 2018 ) did not consider, covered an additional two databases that Cummings et al. ( 2018 ) did not screen, and had a 3‐year longer timeframe, covering publications up to December 2020 rather than August 2017. Moreover, our review had a broader scope than a recent review by Long ( 2020 ), who concentrated only on authentic leadership style, and another by Adams et al. ( 2019 ), who focused on intensive care unit settings and leaders' behaviour in them.

Transformational leadership and its impact on employees' well‐being has been studied extensively in several professional fields, yielding similar results to those discussed here (Gilbert et al.,  2017 ; Jacobs et al.,  2013 ; Kara et al.,  2013 ; Kelloway et al.,  2012 ; Nielsen et al.,  2009 ; Sudha et al.,  2016 ). For example, in hospitality, transformative leadership reportedly has a stronger positive effect on employees' work‐related well‐being than transactional leadership (Kara et al.,  2013 ). Kelloway et al. ( 2012 ) found that non‐transformational leadership styles were negatively connected with trust, which mediated effects on employees' psychological well‐being. These results and those analysed in this review highlight the importance of evaluating leaders' leadership styles when considering nurses' work‐related well‐being. The available data suggest that nurse leaders should be capable of using supportive, empowering, resonant, transformational, transactional, authentic, ethical and servant leadership styles.

All the destructive leadership styles have negative connections to nurses' work‐related well‐being, and each of them were described in one article, except the laissez‐faire style, which was addressed in three studies. This raises questions about why these leadership styles have been studied so rarely. The systematic review by Cummings et al. ( 2018 ) also identified two destructive leadership styles: dissonant leadership and management‐by‐exception with negative associations to nurses' work‐related well‐being based on two studies. Thus, it is important to determine how widely unsatisfactory leadership styles are used, as well as how they affect nurses' work‐related well‐being and other nursing sensitive outcomes. More studies are needed to provide knowledge on characteristics of these destructive leadership styles, how they develop, their connections to adverse outcomes, and ways to prevent their negative effects. However, some relevant results have been presented, for example Lavoie‐Tremblay et al. ( 2016 ) showed that abusive leadership styles negatively affect patient outcomes.

Work‐related well‐being has been mainly evaluated in terms of burnout, in keeping with previous findings of reviews by Awa et al. ( 2010 ), Häggman‐Laitila and Romppanen ( 2017 ), Romppanen and Häggman‐Laitila ( 2017 ), Van Wyk and Pillay‐Van Wyk ( 2010 ) and Westermann et al. ( 2014 ). The instruments used in the included studies have been used widely before and their psychometric properties have been deemed good. It should, however, be noted that results of this review are based on comparatively narrow definitions of work‐related well‐being (Buffer et al.,  2013 ); future studies in this area should address other dimensions of the concept and their associations with nurse leaders' leadership styles. A more comprehensive measurement approach would deepen our knowledge of the association between leadership styles and the promotion of work‐related well‐being. Another limitation of this review stems from methodological approaches of the studies. Their results were based on self‐assessment of work‐related well‐being and response rates were low. In the future, objective measures such as sick leave rates and productivity indicators should also be included in the study designs. Studies were cross‐sectional or follow‐up surveys and although many of them were based on sophisticated multivariate statistical analyses and results of the studies were consistent, the strength of the evidence remains low. Intervention and longitudinal studies are therefore needed to obtain stronger evidence regarding associations between nurse leaders' leadership styles and nurses' work‐related well‐being. The studies should also be replicated in different settings. We need also research‐based evidence regarding interventions' content and approaches that can fruitfully develop nurse leaders' leadership styles. Although we have some evidence of interventions such as coaching, summits, mentoring or workshops for nurse leaders, more studies are needed to identify what kind of leadership interventions are the most effective and the study designs need to be stronger. It is also pivotal to acknowledge the contextuality of the leadership practices and the influence of the whole team and culture on the work‐related well‐being, not just the individual relationships between nurse leaders and nurses (Cummings et al.,  2021 ).

The results of our review of indirect effects of leadership styles on work‐related well‐being and the mediating factors underline the complexity of the focal phenomena. Many factors may interactively influence experiences of nurses' work‐related well‐being and the complexity requires further attention. Our review also showed that leadership styles can influence diverse other important variables, such as nurses' job satisfaction (Bobbio & Manganelli,  2015 ; Kaffashpoor & Sadeghian,  2020 ; Munir et al.,  2012 ), incivility (Laschinger et al.,  2014 ), empowerment (Laschinger et al.,  2013 , 2014 ; Read & Laschinger,  2015 ), turnover (McKenna & Jeske,  2021 ; Pishgooie et al.,  2018 ), early career burnout (Laschinger & Fida,  2014 ; Trepanier et al.,  2019 ), affective commitment (Trepanier et al.,  2019 ), psychological detachment from work (Majeed & Fatima,  2020 ), work climate (Nelson et al.,  2014 ), worklife and the development of trustful relationships (Read & Laschinger,  2015 ). Organizations should concentrate on creating structurally empowering work environments (Laschinger et al.,  2013 ), trusting relationships and positive workplace environment (Read & Laschinger,  2015 ) when developing leadership styles of their leaders. When these factors are developed in the interventions together with leadership styles, we can assume that the interactivity of the factors produce positive comprehensive effects on the work‐related well‐being. We need future studies to develop these many‐sided interventions and to evaluate their effectiveness by objective measurements (Cummings et al.,  2021 ).

Appropriate leadership styles are essential for creating healthy work environments, promoting nurses' well‐being, and avoiding high turnover. In addition to these nurse workforce outcomes, nurse leaders' performance influences patient outcomes (Goedhart et al.,  2017 ; Lavoie‐Tremblay et al.,  2016 ; Wong et al.,  2013 ). Healthcare organizations are complex systems and leaders must be comfortable using several different leadership styles in different situations. Leaders must also be aware of their own leadership styles and their effectiveness and the mediating factors in the work environment regarding employees' work‐related well‐being, and constantly seek to improve their own skills and work environment. This is greatly facilitated by the support of superiors. Leaders need more knowledge on how to identify the differences between the different leadership styles and how to apply supportive and relationally focused styles instead of destructive styles. They also need training on how to use different leadership styles in different situations. The training should be systematic, evidence‐based and cover all levels of the organization. It should also provide a deep understanding of the complexity of the phenomena.

4.2. Limitations

Several limitations of this study have already been highlighted, but some others should also be mentioned. The search process was conducted with an information specialist using database directories in efforts to ensure that the search was sufficiently systematic and extensive. The search terms and selection process have been described in detail above to allow repeatability. Several electronic databases were searched, and the results were complemented by reviewing reference lists of articles included in the final sample to minimize the likelihood of selection bias. The language selection criterion may have caused the exclusion of relevant studies published in languages other than English or Finnish. The grey literature was not taken into account in the review. This may have also increased the probability of bias when acquiring material to review. The reliability of the analysis was increased by using a matrix, in which the analysed articles are described in detail.

5. CONCLUSION

This systematic review of quantitative studies clearly showed that nurse leaders' leadership styles significantly influence nurses' work‐related well‐being. In total, 14 of the reviewed studies focused on 12 leadership styles with positive impacts on nurses. More research is required on unrecommended leadership styles, their prevalence and their impact on nurses' work‐related well‐being. Work‐related well‐being was mainly measured and defined in terms of burnout; this narrow definition prevents a holistic analysis of the relationship between leadership styles and work‐related well‐being. The strength of the evidence in this field appears to be low; intervention studies are needed to get stronger evidence regarding nurse leaders' leadership styles and their direct and indirect impacts on nurses' work‐related well‐being to inform healthcare policy and organizations, educators, and researchers. In the developing of intervention studies on work‐related well‐being, the results of the indirect effects and the mediating factors of the leadership styles should be acknowledged. Because nurse leaders' leadership styles affect nurses' work‐related well‐being, systematic evaluation of these styles in organizations is important. Organizations should invest in nurse leaders' education. Results of this review could be used when developing work environments, planning and implementing leadership training.

CONFLICT OF INTERESTS

The authors declare no conflict of interests.

Niinihuhta, M. , & Häggman‐Laitila, A. (2022). A systematic review of the relationships between nurse leaders' leadership styles and nurses' work‐related well‐being . International Journal of Nursing Practice , 28 ( 5 ), e13040. 10.1111/ijn.13040 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

DATA AVAILABILITY STATEMENT

*Included in the final data of the systematic review

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