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Chapter

Leadership Styles in Nursing

Serpil Çelik Durmuş and Kamile Kırca

Abstract

Recent developments in the field of management-organization and organiza-

tional behavior and new concepts have also led to the emergence of new leadership
styles in leadership. Leadership in health services is important for following innova-
tions and adapting to current situations. Nurses working together with other health
personnel in hospitals providing health services constitute an important group in
leadership. Nursing, which is a key force for patient safety and safe care, is a human-
centered profession, and therefore leadership is a key skill for nurses at all levels.
The leadership styles of nurse managers are believed to be an important determi-
nant of job satisfaction and persistence of nurses. The need for nurses with leader-
ship skills and the need for nurses to develop their leadership skills are increasing
day by day. There are several leadership styles defined in nursing literature. These
leadership styles are examined under the titles of relational leadership style,
transformational leadership, resonant leadership, emotional intelligence leadership,
and participatory leadership. The task-focused leadership style is explored under
the headings of transactional and autocratic leadership, laissez-faire leadership, and
instrumental leadership.

Keywords: nursing, leadership, leadership styles, patient safety, quality of care

1. Introduction

“Leadership is not only about individuals, but also about teams” [1].
Nowadays, leadership in health services is an important issue that aims to
protect and improve human health. Rapid changes and developments in the health
sector increase the importance of developing managership and leadership skills for
health managers [2]. Regional and national health systems tend to redesign their
functions and priorities by making structural changes in social and economic terms
to cope with the increasing health problems [3]. The inclusion of complex technol-
ogy and intense human relations in hospital services, which constitute a significant
part of health care services, leads to the emergence of important managerial prob-
lems [4]. The existence of effective, creative, visionary, motivated, knowledgeable,
principled leaders for the development of the institution is important to eliminate
various problems in health services. To be able to do this, it is necessary to deter-
mine the qualifications that can contribute to the effective leadership of corporate
managers [2, 5].
Leadership in health services is of great importance in terms of following
innovations and adapting to existing situations [6]. Leadership can be defined
as a multidimensional process, which means that a person motivates others to
direct their activities and develop their skills under certain circumstances [3, 7].
The leader is the person who sets the goals of his group and who influences and

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Nursing - New Perspectives

directs the members of the group in line with these goals [8]. In addition, a good
leader must be dynamic, passionate, have a motivational effect on other people, be
solution oriented, and try to inspire others. Nurses, who work together with other
health personnel in hospitals, constitute an important group in leadership. Nursing,
which is a key force for patient safety and safe care, is a human-centered profession,
and therefore leadership is a key skill for nurses at all levels. The leadership styles of
nurse managers are believed to be an important determinant of job satisfaction and
job commitment of nurses. Nurses who are mobilized and empowered to perform
specific personal or group goals by a good leader nurse are willing to implement
evidence-based practices and are highly motivated, well informed, and committed
to organizational goals. Therefore, they perform patient care in a more effective and
planned process. It has become imperative to examine the role of leadership styles
of nurse managers on staff outcomes after miscarriage of health workforce, which is
a global nursing problem, increasing health care costs and workload [9, 10].
There is a limited number of articles in the literature about the leadership
styles of nurses. In these studies, the importance of leadership styles and prac-
tices on patient outcomes and patient safety, health service power and corporate
culture were determined [3]. However, Cummings [10] stated that most styles
can be grouped under relational leadership or task-focused leadership. Relational
leadership styles focus on people and relationships. It includes transformational,
emotional intelligence, resonance, and participatory leadership. These styles are
positively associated with staff satisfaction, organizational commitment, improved
staff health welfare, stress reduction, job satisfaction, productivity increase,
effective study, and positive patient outcomes. However, task-focused leadership is
focused on completion of works, deadlines, and directives. Task-focused leadership
styles include operational, autocratic, and laissez-faire leadership [10].

2. Leadership styles in nursing

2.1 Relational leadership

Relational leadership styles focus on people and relationships and include

transformational, emotional intelligence, resonance, and participatory leadership
[11]. These leadership styles are associated with increased employee satisfaction,
organizational commitment, improved staff health and well-being, stress reduc-
tion, job satisfaction, increased productivity, effective work, and positive patient
outcomes [10].

2.1.1 Transformational leadership

Transformational leadership is considered the gold standard of leadership [11].

Transformational leadership is at the center of nursing because it has an impact
on patient outcomes, employee satisfaction, and safety culture. Transformational
nurse leaders first perform nursing, communicate effectively with their audiences,
and become effective role models [12]. Such leaders are motivated and empowering,
encouraging and following their audience for organizational goals and individual
goals [13, 20]. In addition, it is explained how the transformational leaders have
four characteristics that affect their audience. These characteristics are charisma,
inspirational, intellectual thinking, and individual attention [42].
It is thought that the transformational leaders fascinate their audience with
the charisma feature. This fascination is sometimes associated with the physical

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DOI: http://dx.doi.org/10.5772/intechopen.89679

characteristics of the leader as well as communication skills and vision. The inspir-
ing character of transformational leaders supports and motivates their followers
with encouraging speeches in case of hard work and crises [14].
Transformational leaders, with their intellectual characteristics, encourage
their followers to think innovatively and to think about how we can do it better. At
the same time, these leaders do not prefer their followers to accept their thoughts
as they are [14]. Finally, the transformational leaders, who are interested in their
followers individually, advise them in line with their individual needs. In addition,
leaders appreciate their followers within the team.
When considered with a general assessment, transformational leaders think that
their followers should be evaluated individually and the needs and characteristics
of the followers may change with the influence of the leader. Therefore, with the
mentoring of the leader, the development of the followers increases at the same rate.

2.1.2 Resonance leadership

Resonance leadership is based on emotional intelligence and awareness, includ-

ing being open and sensitive to judgment [15]. Resonance leaders have emotional
intelligence features. These are self-awareness, self-management, social awareness,
and relationship management [16]. According to these characteristics, resonance
leaders are effective in managing and solving conflict, democratic, collaborative,
and can find solutions to problems.

2.1.3 Emotional intelligence

Emotional intelligence was first described as a feature of transformational

and resonant leadership in the 1980s. Leaders with emotional intelligence have
four important structures: self-awareness, self-management, social awareness,
and social skills. Emotionally intelligent leaders are sensitive to the well-being,
emotions, and emotional health of themselves and their followers, and develop
effective personal relationships while directing followers to common business goals.
Emotionally intelligent leaders manage and reflect their emotions, making rational
decisions to ensure teamwork and collaboration. Emotionally intelligent leaders are
also effective in conflict resolution because they have the ability to see the situation
from others’ perspective and manage work stress [11].

2.1.4 Participatory leadership

In participatory leadership, the views of individuals and groups are taken into
consideration. Knowledge, experience, skills, and innovation are of great impor-
tance in the decision-making process, with a wide range of expertise and participa-
tion in engagement. In 2016, WHO called for participatory leadership to replace
hierarchical leadership models of health leadership, suggesting that inclusiveness
and the involvement of various stakeholders would strengthen health services [17].

2.2 Task-focused leadership

The task-focused leadership style involves planning business activities, clari-

fying roles within a team or a group of people, as well as a set of objectives, and
continuous monitoring of processes and performance. Task-focused leaders focus
on completion of jobs, deadlines, and directives [10]. Task-focused leadership is
significantly associated with high-level patient satisfaction [18].

3
Nursing - New Perspectives

2.2.1 Transactional and autocratic leadership

“Do it now!”

This concept, which is referred to as “transactional leadership” in English

literature, is used as “interactionist,” “operational,” or “transactional” leadership in
different sources. Transactional leadership is a leadership style that provides short-
term goals and motivates viewers through the fulfillment of individual needs in
exchange for high performance toward organizational goals [19]. Leaders in trans-
actional leadership act as exchanges managers by exchanging followers who lead
to improvement in production, and are interested in processes rather than shared
values with forward-thinking ideas [18, 20].
Transactional leadership style emerges in two basic forms as “management with
exceptions” and “conditional rewarding” [21, 22]. The form management with
exceptions is divided into two as active and passive. The active leader monitors
the performance of the team followers and intervenes to correct these errors when
he/she detects errors. The passive leader expects the followers’ mistakes to draw
their attention before giving negative feedback or any warning [23]. In conditional
rewarding, transactional leaders clearly explain to their followers what their duties
are, how they will be made, and how they will be rewarded if the desired tasks are
fulfilled satisfactorily [21, 24].
Transactional leaders are cultural carriers who maintain the existing order and
act in line with traditions and past [25]. In crises where an explicit orientation is
required, the transactional leadership approach is an effective style. Transactional
leadership can be the best leadership style for the direction of critical events [18,
26]. This leadership style can be effective in emergency situations such as cardiac
arrest, by enabling nurses to focus on the task as a whole on the patient [27].
In the literature, transactional leadership and transformational leadership are
explained together and comparisons are made. Besides, unlike the transformational
leadership, leaders who adopt an interactive approach want to maintain the same
things instead of changing the future, and they are less concerned with the creative
and innovative aspects and focus on concepts such as efficiency and quality [28]. Bass
emphasizes the use of interactive leadership as a conditionally rewarding perfor-
mance, especially among followers and leaders [29]. While transformational leader-
ship results in a performance beyond expected, interactive leadership focuses on the
expected results [30]. According to the transactional leadership, leadership is seen
as a simple mutual exchange between leaders and followers based on economic or
political reasons, while transformational leadership states that leaders and followers
influence each other in order to achieve higher levels of motivation and morale [31].
Another type of transactional leadership is autocratic leadership. Autocratic lead-
ers are defined as directives, controlling, power-oriented, and closed-minded. The
leader describes the “what, when, why, and how” of the task. He/she emphasizes
obedience, loyalty, and strict adherence to the rules. Followers do what the autocratic
leader says [32]. The autocratic leadership style can be considered ideal in emergen-
cies because he or she takes all decisions himself/herself, regardless of the views of
the leading staff [3]. Because information is seen as power, critical information can
be hidden from the team. Mistakes are not tolerated and individuals are accused
rather than erroneous operations. Rewards are given for compliance, but disobedi-
ence is punished [18, 32]. In addition, autocratic leaders can create fear among staff
and often make decisions without consulting the team [32]. These leaders motivate
their subordinates by using their “legal powers,” “rewarding powers,” and “coercive
forces.” Autocratic leaders may not be welcome by their team, but this can be trans-
formed into appreciation and devotion when the positive results of their leadership

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Leadership Styles in Nursing
DOI: http://dx.doi.org/10.5772/intechopen.89679

emerge. Although staff do not like autocratic leaders, they often work well on their
orders [18, 32]. This leadership approach can be useful at the moment when it is
necessary to make quick decisions or to mobilize uneducated and less-motivated fol-
lowers in the short term by pressure and fear [6, 33, 34]. The positive aspect of this
style is that it works perfectly in emergencies or chaotic situations with little time for
discussion.
Schoel et al. found that very popular leaders were perceived as ineffective, while
unpopular leaders could be perceived as effective [35]. According to the results of
Uysal et al., the perception of the behavior of hospital managers as autocratic by
followers decreases the productivity of the work [6], because autocratic leadership
is perceived negatively by the followers; the reason is that the authoritarian attitude
does not give the employee the right to speak, and that the awards and punishments
are precise and clear.

2.2.2 Laissez-faire leadership

The style of leadership recognizing full freedom is also referred to as “laissez-

faire” in the literature and is expressed as “let them do it.” This kind of a leader
advises the process by not participating in the process, encourages followers to
generate ideas, offers suggestions when asked by followers, and declares opinions.
[31]. Leadership that recognizes full freedom is a style in which the leader provides
little or no orientation or control, and prefers a practical approach. Fully free
leadership style includes a leader who does not decide, and acts without staffing or
supervision [3]. The main task of the leader is to provide resources. Such leaders
dissipate responsibilities and retreat and refrain from taking decisions [31]. The
leader only gives his/her opinion when asked about his/her opinion on any subject,
but this view is not binding on his/her followers [36].
Leadership that recognizes full freedom is an authoritative, task-focused leader-
ship style, because it involves the regulation of tasks in times of crisis, so it shows
reactive leadership. This style of leadership is often used by inexperienced leaders or
those who are about to vacate their leadership positions, who prefer to give up their
followers or others to change their positions, such as those who would like to give up
their job [18]. The leader leaves the followers on their own. Followers do what they
think is the best. Followers are trained to find the best solution to their problems.
Whenever he/she sees it necessary, a person can form a group with whom he/she
wants to solve problems, try new ideas, and make the decisions that he/she thinks
are most appropriate for him/her [37, 38].
There are positive and negative aspects of the leadership style that gives full
freedom. The first positive aspect of this leadership style is the determination and
implementation of the goals, plans, and policies of employees or members of the
organization, and it mobilizes the creativity of each member or employee [39]. The
second positive aspect is that employees are motivated to train themselves and find
the most appropriate solution to the problems. When the individual deems it neces-
sary, he/she creates a group with the people he/she wants, solves the problems, tries
new ideas, and reaches the most appropriate decisions [40]. The negative aspects
of leadership, which gives full freedom, are the emergence of turmoil within the
organization and the fact that everyone leads to the targets he/she wants and even
toward opposing targets. Another disadvantage is the significant decrease in organi-
zational success, independent of personal achievements.
Skogstad et al. state that the type of leadership recognizing full liberty reinforces
the role conflict and role ambiguity experienced by the individual, and increases
the conflicts with colleagues [40]. Hinkin et al. also state that leadership behaviors
that recognize full liberty harm the punitive and rewarding roles of the leader

5
Nursing - New Perspectives

and decrease leaders’ effectiveness [41]. Chaudhry and Javed state that fully free
leadership has no effect on the motivation of the followers compared to other types
of leadership [42]. Şentürk et al. reveals that fully free leadership does not have
a reinforcing effect on innovative behaviors but rather reduces it [31]. According
to the results of Uysal et al., the perception of the behavior of hospital manag-
ers as autocratic by followers decreases the productivity of the work [6]. Because
autocratic leadership is perceived negatively by the followers. The reason is that the
authoritarian attitude does not give the employee the right to speak, and that the
awards and punishments are precise and clear.

2.2.3 Instrumental leadership

Instrumental leadership focuses on choosing an appropriate strategy along with

appropriate resources to achieve business goals, and it is vital for sustainable cor-
porate performance [43, 44]. This leadership style is part of the spectrum of trans-
formational and interactive leadership styles. Instrumental leaders can be effective
managers because they ensure efficiency protection. Thus, jobs are completed in line
with the resources, strategic vision, and time constraints of the health facility [45]. In
current leadership approaches, the strategy and task-focused developmental func-
tions of the leaders are not taken into account; however, strategy and task-focused
functions, which are instrumental forms of leadership, are essential for organizations
and followers to ensure sustainable performance. Instrumental leadership is based on
neither ideals nor swap relationships. Instrumental leadership includes ensuring har-
mony between the organization and the environment, developing strategies, prepar-
ing task and strategy tables, using resources effectively, and providing performance
feedback [44]. The most prominent feature of the instrumental leadership type is the
determination of the subordinates’ path by the leader [34]. The instrumental leader is
mainly concerned with the timely completion of the work related to the desired goal;
it focuses on functions such as setting goals, organizing group members, setting up
the communication system, and determining work-related times [46]. Akyurt et al.
found that instrumental and interactive leadership have a statistically significant and
positive effect on job satisfaction and organizational commitment [21]. Tengilimoglu
and Yigit, in their study on 355 state hospital workers in order to determine the effect
of leadership behavior in hospitals on job satisfaction of the employees, found that
the leadership style with the highest job satisfaction were participatory, instrumen-
tal, success-oriented, and supporting leadership, respectively [34].

3. Effective leadership

As the health sector is in a process of change, new leadership approaches need

to be implemented to effectively manage this new structure [46]. Developments
in the field of management-organization and organizational behavior and new
concepts have also led to the emergence of new leadership styles in leadership [4].
Leadership is important for every organization as well as for health organizations,
because the success of an organization is a good leader [47]. For effective leadership,
it is important to focus on the dynamic relationships between guidance, leadership
values, culture, talent, and organizational context [48]. Effective leaders in health
care services consider safe, qualified, and friendly care as the top priority. Effective
leadership is critical to facilitate quality care, patient safety, and positive staff devel-
opment. Leaders make the voice of patients continuous; they continuously monitor
their patient experiences, concerns, needs, and feedback [49]. Nurses, the largest
workforce in a health institution and a dynamic profession, play an important role

6
Leadership Styles in Nursing
DOI: http://dx.doi.org/10.5772/intechopen.89679

in health leadership and policy-making, while maintaining their traditional care

skills [50]. The leadership style of executive nurses plays an important role in the
provision of job satisfaction and motivation of nurses, development of institutional
commitment, and effective management of conflicts [51–53]. In addition, effective
leadership styles can increase the quality of health care outcomes. In addition, lead-
ership in health facilities is considered as an important factor in ensuring quality
health services, patient satisfaction, and financial performance.

4. Conclusion

Nurses are responsible for guiding the community because of their responsibili-
ties in health care. Patient care and education, effective communication, and clinical
management are the most important tasks. These tasks are closely related to leader-
ship behavior. Nurses who exhibit leadership behavior will be pioneers in bringing
the profession to a professional level. The goal of future health care institutions
should be to influence the quality of patient care through a good nursing leadership.
Future research should focus on the development, applicability, and implementa-
tion of robust leadership style models in different health environments. These
studies should include multidisciplinary professional teams; strengthen the role of
nurses and other health professionals; and address organizational parameters and
individual wishes, preferences, and expectations for quality of life and health care.

Acknowledgements

We thank everyone who provided scientific guidance.

Conflict of interest

The authors declare no conflict of interest.

Author details

Serpil Çelik Durmuş1* and Kamile Kırca2

1 Nursing Management Department, Faculty of Health Sciences,

Kırıkkale University, Kırıkkale, Turkey

2 Nursing Department, Faculty of Health Sciences, Kırıkkale University, Kırıkkale,

Turkey

*Address all correspondence to: [email protected]

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms
of the Creative Commons Attribution License (http://creativecommons.org/licenses/
by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.

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Nursing - New Perspectives

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