Background: Leadership is critical in building quality work environments, implementing new models of care, and bringing health and wellbeing to a strained nursing workforce. However, the nature of leadership style, how leadership should be enacted, and its associated outcomes requires further research and understanding. We aimed to examine the relationships between various styles of leadership and outcomes for the nursing workforce and their work environments. Methods: The search strategy of this systematic review included 10 electronic databases. Published, quantitative studies that examined the correlations between leadership behaviours and nursing outcomes were included. Quality assessments, data extractions and analysis were completed on all included studies by independent reviewers. Results: A total of 50,941 titles and abstracts were screened resulting in 129 included studies. Using content analysis, 121 outcomes were grouped into six categories: 1) staff satisfaction with job factors, 2) staff relationships with work, 3) staff health & wellbeing, 4) relations among staff, 5) organizational environment factors and 6) productivity & effectiveness. Our analysis illuminated patterns between relational and task focused leadership styles and their outcomes for nurses and nursing work environments. For example, 52 studies reported that relational leadership styles were associated with higher nurse job satisfaction, whereas 16 studies found that task-focused leadership styles were associated with lower nurse job satisfaction. Similar trends were found for each category of outcomes. Conclusions: The findings of this systematic review provide strong support for the employment of relational leadership styles to promote positive nursing workforce outcomes and related organizational outcomes. Leadership focused solely on task completion is insufficient to achieve optimum outcomes for the nursing workforce. Relational leadership practices need to be encouraged and supported by individuals and organizations to enhance nursing job satisfaction, retention, work environment factors and individual productivity within healthcare settings.

Introduction

As healthcare systems across the globe continue to experience relentless and turbulent change, the appeals and opportunities for healthcare professionals, especially nurses, to provide effective and visionary leadership to address the challenges and consequences of system reform have never been greater (Duncan et al., 2014; Institute of Medicine (IOM), 2011). Economic constraints that trigger demands for new models of care with skill mix changes in hospital care in order to reduce costs (Aiken et al., 2017) are significant in many countries and contribute to a climate of increased managerialism that promotes efficiencies at the expense of positive transformative changes in care quality (Duncan et al., 2014; Gilbert, 2005; Wong, 2015). Ongoing concerns about nurse and leader shortages (Titzer et al., 2014) along with complaints of overloaded and disenchanted nursing workforces point to the importance of healthy and productive work environments in sustaining the health and well-being of nurses (McHugh et al., 2011; Shirey, 2017; Van Bogaert and Clarke, 2018). Despite the widely recognized importance of leadership in creating healthy work environments, there is much debate in the literature as to what constitutes effective leadership in a context of these dynamic workplace challenges (Albert, 2016; Sherman and Pross, 2010). Effective leadership practices to address these challenges must be informed by current empirical findings of the effects of nursing leadership styles on nurse outcomes. Leadership is studied within numerous fields including psychology and education, military, management, healthcare and specifically, nursing. Conceptualizations of leadership are typically defined by four central elements: leadership (a) is a process, (b) entails influence, (c) occurs within a group setting or context, and (d) involves achieving goals that reflect a common vision (Hunt, 2004; Northouse, 2007; Shaw, 2007; Shortell and Kaluzny, 2006). Frequently used leadership theories including transformational leadership, emotionally intelligent leadership, and authentic leadership have guided nursing leadership research and interventions, likely based on their emphasis on relationships for effecting positive change or outcomes (Gardner et al., 2005a,b; Hibberd et al., 2006). We used Northouse’s definition of leadership – “a process whereby an individual influences a group of individuals to achieve a common goal” (Northouse, 2007). Leadership styles can be generally categorized as focusing on human relationships or task completion.