International Journal of Africa Nursing Sciences 18 (2023) 100564

Contents lists available at ScienceDirect

International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Systematic Review of Head Nurse Leadership Style and Nurse Performance

Mohammed Qtait
PHD Candiate, Nursing debertment, Arab american university, Palestine

A R T I C L E I N F O A B S T R A C T

Keywords: Background: In any group, the leaders are the ones who carry the blood supply. Because leaders inspire and
Nurse performance motivate their teams, those under them may accomplish more with less effort.
Leadership behaviors Aim: The purpose of this study is to describe and assess the leadership of head nurses and their impact on nurse
Head nurses
performance.
Methods: This interdisciplinary systematic study’s search strategy made use of three different internet databases
Scopus, PubMed and google scholar. Quantitative studies of the leadership styles and performance of head nurses
have been conducted and published. All included studies had their data extracted, analyzed, and assessed for
quality.
Finding: From 10,712 initial titles, 12 studies were selected quality evaluations were conducted. After the quality
evaluation, two more quantitative studies were taken out because they didn’t fit with the purpose of the review.
Conclusion and Implications: Any healthcare provider should work to improve patient care. Leaders in the nursing
profession play an important role in ensuring that their teams fully comprehend the needs and values of their
patients. There is evidence that the leadership styles of managers have an impact on nurses’ productivity. Nurses
should be questioned by researchers and healthcare institutions on how leadership styles affect their work.
Leadership improves performance. Democratic and transformational leaders have a positive impact on perfor­
mance. Recognizing and addressing the factors that affect nurses’ ability and motivation to succeed can raise
their performance. Two more quantitative studies were discarded after the quality evaluation because they were
irrelevant to the review’s stated objectives.

1. Introduction Managers must use specialized leadership methods to deal with different
functional challenges and reach departmental goals in order to boost
A healthcare system must balance the competing goals of enhancing performance. The effects of this link between leadership and overall
public health and minimizing an increase in health costs in an ever- productivity should be easy to see. This is bound to lead to increased
changing environment (Specchia et al., 2021). People have the efficiency, specialization, and solid organizational ties (Armstrong &
impression that leaders are individuals that instill discipline in their Taylor, 2020).
teams while also providing them with the authority to implement In the current healthcare system, nursing performance is concen­
changes that will assist the business achieve its objectives. The study of trated on the quality of treatment, which is typically determined by
how head nurses affect the productivity of their teams is one of the patient outcomes and the achievement of organizational goals (Morrison
nursing research fields that is expanding the fastest. The rest of the squad et al., 1997). Nurses’ ability to go above and beyond their employers’
can’t do anything without their help. This is so because leaders play a expectations and reach organizational targets is influenced by their
crucial part in establishing group norms and assisting team members in leaders’ nursing leadership characteristics (Cummings et al., 2008).
confronting and resolving issues that arise within the context of the It is common for leaders to not know what their workers really want
team. Due to their significant influence on team members, people have and need and to not be able to see the differences between the people on
come up with novel ways for leaders to assist team members. their teams. Problems that were ignored or dealt with too late hurt the
Effective leadership can only make things better for employees, work of team members. Healthcare professionals must take the lead if
which in turn makes them do a better job. In this study, the success of they want to improve the quality and integration of care. Studies have
employees depends on how well they work and how productive they are. shown that a leader’s style has a big impact on the quality of care they

E-mail address: [email protected].

https://doi.org/10.1016/j.ijans.2023.100564
Received 23 September 2022; Received in revised form 10 March 2023; Accepted 20 March 2023
Available online 25 March 2023
2214-1391/© 2023 The Author. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
M. Qtait International Journal of Africa Nursing Sciences 18 (2023) 100564

provide. One of the most significant components in gaining success is nursing, charge nurses, and first line managers. The titles and abstracts
having efficient leadership (Khairunnisa & Nadjib, 2019). Work per­ of the relevant articles were skimmed carefully; (8 0 8) results from all
formance is the success of an organization, but it is not just about one databases (SCOUPS = 115, PubMed = 122, Google schooler = 571) were
person doing their work well because they enjoy it. Inseparable from obtained. According to PRISMA in Fig. 1.
There is a link between the quality of care provided by nurses and the
healthcare facility’s overall aims. (Boamah, 2018). 2.3. Screening
A leader significantly influences a flower’s performance because he
generates a pleasant environment and genuine support for his followers; Using the four criteria for inclusion, the author looked at the titles
they operate with maximum efficiency and obtain the best job outcomes. and abstracts and chose papers and titles that talked about the leader­
(Berger et al., 2019). Staff retention, productivity, and efficiency are all ship and performance of head nurses. For inter-rater reliability, a sample
important considerations for healthcare institutions; thus, nurse leaders’ of abstracts and titles were evaluated using these criteria, and dis­
abilities should be sharpened by utilizing research-based techniques agreements between reviewers were settled by coming to a consensus on
(Adams et al., 2019). One of the essential components of an organiza­ titles and abstracts that were relevant to how head nurses lead and how
tion’s success is the manager’s leadership. The best leaders encourage nurses do their jobs. Using the criteria for inclusion, the author got rid of
their people to do a better job and inspire them to go above and beyond most of the papers, leaving only 12 for quality evaluation and data
the call of duty (NawoseIng’ollan, 2017). extraction.
One of the numerous contemporary nursing leadership theories is the
idea of emotionally intelligent leadership (Al-Motlaq, 2018). According 2.4. Data synthesis
to (den Breejen-de Hooge et al., 2021), research on nursing leadership
primarily focuses on how the behaviors of nursing leaders influence the In a Table S3 and Table S4 In an annex, we used a spreadsheet to list
level of job satisfaction experienced by nurses. To help the organizations each article’s author(s), country of origin, year of publication, research
achieve their goals, nurse leaders must be able to convince nursing staff design, sample, methodology, findings, and limitations.
to adopt positive attitudes and actions.
Most studies on nursing leadership focus on how nursing leaders’ 2.5. Quality appraisal
behaviour affects nurses. Positive patient outcomes are an example of an
organizational objective that nurse leaders must be able to influence and Using the Quality Assessment Tool for Observational Cohort and
promote within their nursing workforce to attain. This paper could give Cross-Sectional Studies, the study’s quality was evaluated. Statistical
healthcare organizations, especially nurse managers and nurse leaders, articles were evaluated using Cummings (Estabrooks et al., 2001).
evidence-based information about what leadership skills head nurses Adapted from (Estabrooks et al., 2001) and the Effective Public Health
need to meet organizational goals of excellence in patient care and what Practice Quality Assessment Instrument (McMaster University School of
leadership qualities are needed to make this happen. Nursing 2003). Cummings and Estabrooks’ instrument evaluates four
To understand the role of leadership in job performance, a systematic aspects of each study: research design, sampling, measurement, and
review was made to collect information about the head nurse’s leader­ statistical analysis; it has been utilized in multiple investigations (Wong
ship and nurse performance from the nurse’s point of view. Based on & Cummings, 2007; Cummings et al., 2008; Lee & Cummings, 2008), as
what we’ve read, it’s clear that not much research is done on what in Fig. 1. In total, there are fourteen elements on this scale that can be
nurses do well, such as whether or not their leadership style affects how answered “yes,” “no,” or “other (cannot determine, inapplicable, or not
well they do their jobs. The purpose of this study was to provide an recorded)” for each. The method evaluates the internal validity of a
explanation of the findings from a systematic review of studies investi­ study by taking into account the possibility of bias. In the end, the
gating the relationship between the leadership styles of head nurses and reviewer rates each study as “good,” “fair,” or “poor,” depending on how
the performance of their subordinate nurses, as well as to make rec­ well the research was done. The risk of bias is used to judge whether a
ommendations for future studies on this topic. Furthermore, the subject study is good, fair, or poor. “Good” means the least risk of bias, “fair”
under investigation is whether there is a correlation between a partic­ means the most risk, and “poor” means the most risk. Due to the need for
ular type of leadership on the part of the head nurse and increased clear instructions on how to evaluate the studies in the tool, the number
productivity on the part of the nurses under her supervision. of items in each tertile of the quality scale was used to rate the studies.
The final grade was based on the number of people who said “yes.”
2. Method According to Table S2, the lowest tertile got a “poor,” the middle tertile
got a “fair,” and the highest tertile got a “good”.
This systematic review of quantitative studies was designed and
carried out according to the Cochrane Collaboration protocols (Higgins 2.6. Quality review
& Green, 2011) and the PRISMA statement (Moher et al., 2009) to
summarize the current research on the relationship between the styles of Each published paper’s methodological quality was rated. (Cum­
leadership used by head nurses and how well their nurses do their jobs. mings and Estabrooks, 2003) Furthermore, Quality Assessment and
Validation Tool for Correlational Studies (Estabrooks et al., 2001) were
2.1. Ethical consideration used to analyze quantitative studies Table S2. (McMaster University
School of Nursing, 2003). Two qualitative studies were critically
Institutional Review Board Statement: Not applicable. reviewed utilizing the CASPT (National CASP collaboration for quali­
Informed Consent Statement: Not applicable. tative methodologies, 2002). Several studies have used Cummings and
Inclusion criteria: according to the Table S1 inclusion and exclusion Estabrooks’ technique to analyze research design, sampling, statistical
criteria. analysis, and measurement (Wong and Cummings, 2007). 14 points can
be given for each of the 13 criteria. Twelve ways to measure the outcome
2.2. Data sources and search strategy were given a score of 0 (not met) or 1. (met). Each study was given a
score of strong (10–14), moderate (5–9), or weak (0–4). Evaluated were
Some of the electronic databases that were searched were PUBMED, confounding factors, blinding, data collection, withdrawals, data anal­
Google Schooler, and Scopus. nurse performance; motivational nursing, ysis, and the integrity of the intervention. Each area is either strong,
nurse performance, and nurse motivation; work performance, Employee fairly strong, or weak. The Critical Appraisal Skills Program asks ten
Performance, and leadership behaviors; and head nurse’s supervisory questions to evaluate qualitative research. Screening questions, study

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M. Qtait International Journal of Africa Nursing Sciences 18 (2023) 100564

Fig. 1. PRISMA

design, sampling, data collection, reflexivity, ethical considerations, 3. Results

data analysis, conclusions, and the value of the research.
808 titles and abstracts were examined (Fig. 1). There was also a
2.7. Data extraction review of abstracts written in English for articles written in other lan­
guages, although these did not quite make the cut. Three hundred
Information about the author, publication year, research goal, sam­ eighty-one papers were assessed for inclusion criteria, and 45 were
ple, independent variables, measurements, and reliability of the excluded. Eleven publications were evaluated for quality, and three
dependent variables were gathered through quantitative studies. Lead­ were selected for further study. Following the quality assessment, two
ership Strategies of Head Nurses and Their Impact on Staff Outcomes. more quantitative studies were removed, as their topic did not clearly
Each article was read once to provide a summary of its content. They connect to this review’s purpose.
were then read multiple times to understand their content better. Both
researchers separately codified descriptions of all recognized examples 3.1. Summary of quality review
of head nurse leadership and nurse performance. These codes were
evaluated, validated, and combined to obtain all the required data ex­ The 12 quantitative studies included in this analysis were deemed to
pressions. They compared the codes based on their similarities and be of moderate or better quality (scores greater than 5). Eight of these
differences. Similar expressions were grouped under the same topic, and studies were sampled from various places, which increased sample di­
the themes were called based on their corresponding content. versity, and the majority of them were theoretically or conceptually
grounded. Sample size was justified by power estimates (0.8) or other

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rules of thumb, such as a minimum sample size of 10 for each inde­ from the nurses. To put it another way, when it comes to the nurses’
pendent variable. Instrumental validity was reported by only one study, perspective, transformational leadership produces better results for the
but reliability was reported by twelve. There were 11 of the 12 studies in organization. Transformative leadership has a good correlation with
which alpha values greater than 70 were reached for characteristics employee performance, according to (Ibrahim et al., 2016).
linked with nurse performance, and one study (Hartono et al., 2020) was A study (Abd-Elrhaman and Abd-Allah, 2018; Niinihuhta and
less than 70, Table S2. Häggman-Laitila, 2022) found that head nurses’ knowledge and abilities
about transformational leadership increased dramatically immediately
3.2. Characteristics of studies included following the program and for three months following the program,
compared to pre-program scores (Quasi-experimental). Staff nurses’
The studies that were included in the meta-analysis are summarized scores on work performance aspects improved significantly throughout
and categorized by broad categories in Table S1. Of the 12 studies the study, immediately following the program’s conclusion and three
published between 2017 and 2022, four were conducted in Egypt (Abd- months later. Recommendations: Head nurses should get ongoing
Elrhaman and Abd-Allah, 2018; Ibrahim et al., 2016; Abdallah et al., training and education so they can stay up to date on the transformative
2021; Ariani, 2021); two in Indonesia (Demirhan, 2020; Ariani, et al., leadership style and what it means. According to (Alloubani et al.,
2022) Turkey (Demirhan, 2020), Saudi Arabia (Alharbi et al., 2021; 2017), (Rashidi et al., 2020, Alharbi et al., 2021, Alsadaan, 2018), and
Alsadaan et al., 2018), Jordan, Italy (Niinihuhta and Häggman-Laitila, (Ibrahim et al., 2016), nurse managers were more likely to use trans­
2022) and Iran (Rashidi et al., 2020). The studies reflected nurse man­ formational and transactional leadership styles than laissez-faire. (Har­
ager or head nurse leadership style and nurse performance. De­ tono et al., 2020;), (Ariani. et al., 2022).
mographic variables of nurses were mentioned in 12. Most studies aim to
find the relationship between leadership style and nurses’ performance. 3.6. Autocratic leadership
Demographics of nurses were reported in all the studies. All respondents
were baccalaureate, and most female’s age pf responders above 28 years Autocratic leadership was the most common type of leadership in
of age with above seven years of nursing experience. family firms at the time of (Dyer’s, 1986) research, primarily because of
the concentration of power among owner-managers (Sorenson, 2000).
3.3. Theoretical framework According to the study of (Ibrahim et al., 2016; Ernawati, 2020), the
autocratic leadership style improves performance. In a study conducted
Among the 12 research, 10 were based on some sort of theoretical by (Peter and Slatkin, 2013), which focused on the link between man­
model or guideline. This is crucial as it provides a theoretical basis for agement styles and the performance of chosen Nigerian employees, it
testing hypotheses and conducting experiments to determine the nature was found that there was a significant association between management
of causal links between concepts and variables (LoBiondo-Wood & styles and job performance. Due to the nature of the job in the business,
Haber 1998). Three studies from 12 were used to measure leadership this study also revealed that employees were significantly more recep­
“Multifactor Leadership Questionnaire” (Abd-Elrhaman and Abd-Allah, tive to autocratic leadership than to other types. According to (Alisha,
2018; Alsadaan, 2018; Rashidi et al., 2020). Furthermore, two studies 2020), Autocratic leadership in nursing will successfully make swift
used (Burns, 2016) study (Abdallah et al., 2021), two studies used judgments when necessary. This could benefit the group in times of crisis
(Covey,2005) leadership; one used the Leadership Behaviors Scale: The or when implementing “zero occurrence” policies (e.g., driving for zero
scale developed by (Ekvall & Arvonen, 1991), one used leadership styles pressure ulcers).
that were developed by (Clark,1998) and adopted from (Elsayed, 2005),
one use Leadership scale (Northouse,1999). 3.7. Democratic leadership

3.4. Leadership style A democratic leadership style involves leaders who use a participa­
tory approach to decision-making, allowing all group members to have a
When it comes to family business leadership styles, Dyer (1986) voice in the process (Iqbal et al.,2015). The leader’s proclivity to provide
established seven significant categories: autocratic, transformational feedback on performance is a source of employee growth. The re­
management style expert, participatory management style expert, sponsibility and flexibility to make crucial decisions provided to workers
laissez-faire, referent, and transactional. When it comes to leadership increase their morale and motivation (Roussel, 2011). (Demirhan, 2020)
styles, transformational leadership is one of the most well-known and is conducted a survey in which the nurses said their top managers had the
also common in family businesses (Arnold, 2017). most democratic leadership style. Nurses who lead democratically have
faith in their leadership and encourage them to participate in decision-
3.5. Transformational leadership making. According to the study of (Ariani, 2021), the leadership style of
Democratic leaders has a big and positive effect on how well Job does his
Transformational leadership is described (Burns, 1978) as a tech­ job. Democratic leadership demonstrates an attitude of working as a
nique that transforms individuals and societal systems. It transforms team based on the respect and trust of individual members to complete
followers into leaders in its ideal condition by encouraging them to make the task. When the ward was running smoothly and employees were
significant and reasonable changes in their own lives. When applied, getting on with their work of caring for patients, managers said they
transformational leadership increases the drive, self-esteem, and pro­ adopted a democratic leadership style. So, the nurses had a better time at
ductivity of people led by it. Transformational leadership has been work and felt more confident about taking on new responsibilities.
linked to improved patient care and fewer adverse events (Wong et al.,
2013) and may impact nurses’ willingness to stay in the profession 3.8. Measurement of performance for nurses
(Wang et al., 2019). Furthermore, a higher proportion of work perfor­
mance is linked to nurses’ ability to exercise transformational leader­ Seven tools were utilised in the 12 quantitative research to evaluate
ship. Transformative leadership approaches used by clinical nurse nurse performance. Alloubani et al., 2019) used the For their work-
managers as self- and observer-assessed varied greatly, according to related diagnostic survey, they (and others) used the Job Self-Efficacy
(Alharbi et al., 2021). According to (Alsadaan, 2018), in trans­ Questionnaire (Rashidi et al., 2020). In two studies (Ibrahim et al.,
formational leadership elements, nurses thought that nurse managers 2016), a performance evaluation devised by Cobb (2008) was used
with more excellent transformational leadership characteristics would (Abd-Elrhaman and Abd-Allah, 2018).’ The Motivation Scale of Nurses
result in increased work satisfaction, effectiveness, and additional effort Staff was created (Engin and Cam, 2016) and is used (Demirhan, 2020).

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M. Qtait International Journal of Africa Nursing Sciences 18 (2023) 100564

Maslow’s hierarchy of requirements was adopted (Hartono et al., 2020) Nursing Performance is characterized by a competent level of
and used (Ariani, 2021). (Binyo et al. 2009); derived from (Liang et al., nursing conduct in the professional position, comprising actions linked
2001; Saleh, 2021; Abdallah, 2019) and used the (Belkacem, 2017) scale to the quality of care, performance assessment, education, collegiality,
in their studies (Ernawati, 2020). cooperation, research, and resource use (American Nurses Association,
2001). As highlighted by (Patrick et al., 1994), various procedures have
3.9. Leadership and performance been investigated, with nursing performance ratings evaluated by
different raters utilizing a questionnaire. In addition, the tools employed
There was a good association between the quality of nursing care and are genuine and reliable.
the transformational leadership style, according to (Alloubani et al., When a head nurse demonstrates concern, care, and respect for
2019). Furthermore, according to (Ernawati, 2020), the leadership po­ colleagues, it raises their interest in their work and enables them to
sition and assertiveness of head nurses had a substantial impact on the achieve higher performance levels (Wang et al., 2010). The research
accomplishment performance of staff nurses. However, Trans­ showed that competent leadership is the most crucial aspect for the
formational and interchangeable leadership styles have more excellent success of a nursing organization, except with a study (Marquis and
mean self-efficacy scores than the non-intervention approach. A blend of Huston, 2009), the outcomes for patients and the overall performance of
transactional and transformative leadership styles is therefore recom­ the organization might be affected by the leadership style of a nurse
mended for supervisors, depending on which type of leadership is used. manager. In the health sector, nurses play a critical role. Leaders’
(Rashidi et al., 2020). According to (Ibrahim et al., 2016) statistically management influences nurses’ performance and patients’ pleasure.
significant link was established between leadership styles and nurses’ Nurses’ performance is affected by how leaders manage them. One of the
performance. For staff nurses immediately following and three months measures of nursing care quality is patient satisfaction (Alloubani, el,
after (Abd-Elrhaman and Abd-Allah, 2018) found a statistically signifi­ 2017). According to the research, strong leadership is one of the most
cant improvement in job performance indicators compared to their critical criteria for leading a business to success. Recognizing the effects
preprogram ratings. According to this study’s findings (Demirhan, of effective leadership on nursing performance and the success of the
2020), nurse managers exhibit strong leadership qualities and excel in organization is currently the most significant challenge for contempo­
their roles. A favourable rising in managers’ leadership behaviours rary organizations (Alloubani et al., 2014).
boosts the work performance of the nurses. Nursing performance might Many styles are used for head nurse transformational leadership
be improved under the direction of the inpatient room’s chief executive style, as (Alloubani et al., 2019) agreed with the study (Ismail et al.,
officer. There is no doubt that (Hartono et al., 2020) is an expert in his 2009) that people who use transformational leadership style show high
field. (Ariani, 2021). According to the findings, nursing performance performance.
was substantially connected with her leadership style. Table S2 author
and purpose of the study. 4.1. Implications for nursing management

4. Discussion There are a variety of implications for hospital administrators, nurse

managers, teaching and research based on the findings of the current
This systematic review of studies revealed that the leadership styles study. Nursing and patient satisfaction are crucial considerations for
of head nurses greatly affected the performance of nurses. The results administrators when deciding on any leadership style, which should be
were consistent even though the experiments were conducted in six consistent with the institution’s values and goals.
different nations. Nurse managers should also be educated on the various leadership
The review papers employ-six measures designed to measure lead­ styles and how to use the style that best suits the institution’s goals.
ership. High validity (Avolio and Bass, 2004) indicated that the Multi­ Clinical leadership practice and various leadership styles should be
factor Leadership Questionnaire reliably measured each leading factor included in the nursing curriculum to improve students’ educational
across the nine data sets. According to their research (Avolio and Bass, opportunities. Nursing should learn about several leadership styles in
2004), the MLQ tool displayed great internal consistency. The most the clinical setting, and they should be aware of the advantages and cons
frequently investigated leadership styles were relationally focused: and of each and the predicted influence on patient and nurse satisfaction. In
transformational, connected with nurses’ performance. It is important to terms of research, more studies are needed to examine the influence of
remember that there are three levels in the organization; the leader, the culture on nurse managers’ adoption of specific leadership styles.
follower, and the relationship to offer performance. In addition, the Managers in nursing should frequently solicit feedback on their
independent variables are leadership style (autocratic, transformational, leadership performance and make any necessary adjustments. In order
transactional, and Laissez-faire), and the dependent variables are to generate a shared vision for the implementation of optimal leader­
nursing performance. Transformational leadership and its impact on ship, hospital administrations should provide additional support to
nurses’ performance is the study (Alsadaan, 2018; Alharbi et al.,2021; nursing managers through training in effective leadership, encultura­
Ibrahim et al., 2016; Ariani, 2021) that accepts another study (McNaron, tion, and team building.
2009; Wang et al., 2021). In research conducted in a multicultural The findings indicate that the different leadership styles mentioned
setting by (Suliman, 2009; Zampieron et al., 2013; Alyami et al., 2017), in the study (authoritative, laissez-faire, transactional, and trans­
the nurse managers assessed their leadership styles as more trans­ formational) have significant positive correlations with one another,
formational than their staff did (nurses). Several more research (García- except the authoritative leadership style, which has a negligible nega­
Morales et al., 2008; Salanova et al., 2011) have found beneficial effects. tive relationship with employee performance. Transformational lead­
The authoritative leadership style has a weakly negative link with ership is the most effective leadership style, followed by transactional
nursing performance. The traditional approach influences communica­ and laissez-faire. The transformational leadership style is the most
tion between the leader and the followers, which can negatively affect effective, followed by the transactional and laissez-faire leadership
organizational outcomes (Hackman & Johnson, 2013). According to styles. Except for inspirational motivation, which had a weak but posi­
studies by (Ibrahim et al., 2016; Ernawati, 2020), the autocratic lead­ tive relationship with employee performance, transformational leader­
ership style improves performance. In a study conducted by (Peter and ship scores were shown to have a solid and positive relationship with
Slatkin, 2013), which focused on the link between management styles both measures of employee performance.
and the performance of chosen Nigerian employees, it was found that
there was a significant association between management styles and job
performance.

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4.2. Conclusion quality assurance, 32(6), 1022–1033. https://doi.org/10.1108/IJHCQA-06-2018-

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Mohammed Qtait currently works at the Hebron government hospital as head nurse for
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Science Nursing, and Nursing Science. Lecturer in University, and burn He has worked as a
between nurse leaders’ leadership styles and nurses’ work-related well-being.
nurse in the ER. 2007 In 2017. know is PHDc in nursing science in Arab American
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