Nursing leadership styles and their impact on intensive care unit quality measures - An Integrative review

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(1)UEF//eRepository DSpace Rinnakkaistallenteet. https://erepo.uef.fi Terveystieteiden tiedekunta. 2021. Nursing leadership styles and their impact on intensive care unit quality measures - An Integrative review Kiwanuka, Frank Wiley Tieteelliset aikakauslehtiartikkelit © 2020 John Wiley & Sons Ltd All rights reserved http://dx.doi.org/10.1111/jonm.13151 https://erepo.uef.fi/handle/123456789/24343 Downloaded from University of Eastern Finland's eRepository.

(2) Accepted Article. Title: Nursing Leadership Styles and their Impact on Intensive Care Unit Quality Measures – An Integrative Review Running heading: Nursing Leadership and Quality Measures Author details Frank KIWANUKA, BNurs, CNS, PhD student, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Rose Clarke NANYONGA, RN PhD, Vice-Chancellor & Senior Lecturer, Clarke International University, Kampala, Uganda Natalia SAK-DANKOSKY, RN, PhD, Assistant Professor, Department of Clinical Nursing, Medical University of Warsaw, Warsaw, Poland Patience A. MUWANGUZI, RN, PhD, Lecturer and Chair, Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, Kampala, Uganda Tarja KVIST, RN, PhD, Professor, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Correspondence: Frank Kiwanuka, Address: Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, 70211, Kuopio, Finland Email: franki@uef.fi, Tel: +358449684009. Author Contributions FK, RCN, NSD, PAM & TK were responsible for the study design, intellectual content, read and approved the final manuscript. FK was responsible for conception, and data collection. FK, RCN & NSD conducted the methodological appraisal of the included studies. RCN, NSD, PAM & TK were responsible for overall supervision. Funding Statement FK has an EDUFI fellowship grant from the Finnish National Agency for Education. No other Funding to declare for this project. This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/JONM.13151 This article is protected by copyright. All rights reserved.

(3) Accepted Article. Conflict of Interest No conflict of interest declared.. This article is protected by copyright. All rights reserved.

(4) Accepted Article. DR FRANK KIWANUKA (Orcid ID : 0000-0001-8178-3120) DR TARJA KVIST (Orcid ID : 0000-0001-5974-8732). Article type. : Review Article. Nursing leadership styles and their impact on intensive care unit quality measures – An Integrative review. Abstract Aim: To examine the impact of nursing leadership styles on intensive care unit quality measures. Background: Evidence on the impact of leadership styles has direct implications for building and strengthening leadership behaviors that foster quality nursing care in intensive care units. Evaluation: An integrative review approach was adopted. Databases including the Cumulative Index of Nursing and Allied Health Literature, PubMed, Scopus, ProQuest, Google Scholar, and the Cochrane Library were searched.. Key issues(s): Out of 253 identified studies, seven were included in the review. Leaderships styles in intensive care units include transformational, considerate, exemplary, trusted and absentee leadership. Active nurse leaders who share a common vision, and advocate for their staff are perceived as more effective than those who exhibit absentee characteristics. Structural measures influenced by leadership styles include productivity, and morale of. nursing staff. Outcome measures such as staff outcomes (intent to stay, job satisfaction),. medication errors, and periventricular/intraventricular hemorrhage in neonatal intensive care units have a positive relational effect with nursing leadership style. Conclusions: The findings highlight the link between nursing leadership styles on structural and outcomes measures in intensive care units. The current literature lacks studies. This article is protected by copyright. All rights reserved.

(5) Accepted Article. highlighting the impact of nursing leadership styles on process measures in intensive care units.. Implications for nursing management: Transformational, considerate, exemplary leadership practices, and trusted leadership styles when used by nurse leaders guarantee higher quality of nursing care in intensive care units. Therefore, modern leadership styles need to be supported by healthcare organizations, and education.. Keywords: leadership styles, nursing, intensive care units, quality measures, nursing. management. Introduction The world is experiencing unprecedented change in healthcare systems and. demographics. In particular, there is a surge in the demand for frontline providers and intensive care units (ICU) due to the COVID-19 pandemic (Litton et al., 2020). Nursing leadership is crucial to making decisions in healthcare, yet the decision-making process ought to be grounded on credible evidence (Shayan, Kiwanuka & Nakaye, 2019). Accordingly, there is substantial advocacy for nurses’ involvement in healthcare leadership and policy development (Tønnessen et al., 2020). Unfortunately, attempts to achieve greater involvement in healthcare leadership and policy development is partly confounded by lack of evidence on nurses’ influence on healthcare quality measures. It is therefore important to understand the impact of nursing leadership styles on quality measures in intensive care settings. This paper specifically examines the impact of nursing leadership styles on quality measures in ICUs. Background Nursing leadership has substantial impact on quality measures, which is particularly. important when seeking to improve nursing staff welfare or implement new approaches to care (Cummings et al., 2018). Literature on effective nursing leadership theories and styles is expansive. Bass and Avalio (1994) asserted that three sets of leadership theories (transformational, transactional and laissez-faire) are specifically tied to leadership styles. This set of leadership styles constitutes the Full Range Leadership Model (FRLM). The. This article is protected by copyright. All rights reserved.

(6) Accepted Article. Transformational leadership (TL) style has been extensively studied and frequently cited as the most favored and desired leadership style within nursing and other disciplines (Doody & Doody, 2012, 2015; Wu et al., 2020). TL is characterized by individual consideration, intellectual stimulation, inspirational motivation and idealized influence (Bass & Bass, 2008). Transactional leadership is another common leadership style (Solà’ et al., 2016); it is characterized by management by exception and contingent rewards. Other leadership styles include Laissez-faire leadership, authentic leadership, resonant leadership (Laschinger et al., 2014), relational, situational or task-oriented leadership, and situational leadership (McCay, Lyles, & Larkey, 2018). The Laissez-faire leadership style is characterized by the superior’s avoidance and inaction when subordinates are experiencing a situational need for leadership, has also been identified in some care settings. Authentic leadership is an inclusive leadership model that articulates attributes of other leadership models. Authentic leadership is a pattern of leadership traits that draws upon, promotes positive psychological capabilities and an ethical environment (Wong & Walsh, 2020). Leadership styles directly and indirectly affect quality measures. Wong and. Cummings (2007) found that transformational leadership is associated with reduced adverse patient events and enhanced patient satisfaction. Transformational and authentic leadership styles are associated with retention of nursing staff and vibrant working environments, while dissonant leadership styles are associated with undesirable impacts on the nursing workforce. and working environments (Cummings et al., 2018). McCay, et al., (2018) reported that. relational leadership traits contribute positively to nurse satisfaction and retention whilst taskoriented styles reduce nurse satisfaction. The relationship between nursing leadership and patient outcomes is evident in some. care settings. Cummings and colleagues (2010) assessed the associations between five nursing leadership styles (high resonant, moderately resonant, mixed, moderately dissonant and high dissonant) and patient mortality rates in acute care settings. The researchers demonstrated that a 30-day patient mortality was independently associated (p<0.01) with nursing leadership styles. Thirty-day mortality was lowest for two styles: dissonant (4.3%) and high-resonant leadership style (5.2%) (visionary, coaching, affiliative, and democratic) (Cummings, Midodzi, Wong, Estabrooks, 2010). Similarly, a review conducted by Wong et. al., (2013) demonstrated that there is a relationship between leadership and patient mortality. Quality measures in intensive care units. This article is protected by copyright. All rights reserved.

(7) Accepted Article. Quality measures serve as the basis of impact assessments of innovations in patient. care and are also used to define quality and cost targets (Dimick, 2010). According to the Donabedian (1988) healthcare quality model, three types of quality measures can be used to assess healthcare quality: structural measures, process measures, and outcome measures. Structural measures relate to professional and organizational resources as well as the health. information management systems used in clinical care. Professional and organizational resources associated with the provision of care comprise staff credentials and facility operating capacities. Structural measures focus on diverse resources including intra-hospital telehealth services between the ICU and other units (Dumitrascu & Demaerschalk, 2017). In the ICU, process measures include nursing-sensitive quality indicators (Chen et al., 2017), physician expertise and ICU resources needed to perform procedures (Braun et al., 2010). Outcome measures reflect the changes in the health of individuals, groups of people,. or populations that are attributable to an intervention or a series of structural and process interventions. Important outcome measures include mortality, readmission, patient and family experience, and staff outcomes. Outcome measures in ICUs include mortality, outcomes of infection control, prevention of gastrointestinal bleeding and pressure ulcers, prevalence of sepsis, central line associated bloodstream infections (Lee et al., 2019; Pharande et al., 2018), ventilator acquired pneumonia (VAP), and catheter-related bloodstream infections. ICU staff. outcomes include morale, productivity and job satisfaction (Cummings et al., 2018). Although the influence of leadership on quality of care is widely recognized, few. published studies have examined nursing leadership in ICU and its impact on quality measures. Understanding how leadership-related attributes influence quality measures is essential for improving healthcare quality as ICUs expand. In addition, current healthcare quality improvement efforts seem to lack a strong nursing leadership presence; nurse leaders appear to be restricted to rather general contributions that do not exploit their potential to improve competitiveness. Healthcare leaders must look beyond expansion of ICUs to developing effective leadership styles. This must be informed by evidence on the impact of. nurse-leadership on quality measures. There is thus a clear need to explore nursing leadership styles and their impact on quality measures in ICUs. The aim of this review was to examine the impact of nursing leadership styles on quality measures in ICUs. METHODS Design. This article is protected by copyright. All rights reserved.

(8) Accepted Article. An integrative review approach (Whittemore & Knafl, 2005) was adopted. To. enhance the rigor of our review, the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2009) were used.. Search strategy An a priori search in Google scholar, Prospero, and the Campbell collaboration library. was conducted to identify any similar reviews that are in progress or already published. The results indicated that no similar review exists. Literature searches were then performed in the Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed/MedLine, Scopus, Google scholar, ProQuest, and the Cochrane Library (Supplementary information I). Keywords were combined during these database searches to maximize the likelihood of. obtaining relevant hits. The keywords included “nurses, nurse leaders, nurse directors, chief nursing officers, nurse care coordinator, nurse care coordinator roles, leaderships styles, nurse managers, nursing management styles, nursing, intensive care, intensive care units, critical care units, job satisfaction, nurse turnover, quality of care, productivity, performance, effectiveness, quality measures, mortality, readmission, patient experience”. Articles were screened against pre-defined criteria (table I) before inclusion in the final analysis. The reference lists of the included articles were also searched to identify any additional pertinent literature. Data collection Selection of studies: A total of 243 potentially relevant articles were identified during. the database searches, and a further 10 potentially relevant articles were identified by manually searching the reference lists of articles initially selected for inclusion in the review. The titles and abstracts of all 253 articles were thoroughly read by the researchers. Articles that appeared relevant to the focus of the review based on this initial inspection were then fully read. Justification for exclusion was discussed whenever there was uncertainty about an article’s relevance. The main reason for exclusion of studies was not reporting on nursing leadership styles or quality measures in intensive care units. Seven studies were included in the final analysis (figure I). Data items: The primary outcomes included nursing leadership styles and quality. measures. Quality measures included structural, process, and outcome measures. Structural measures included measures relating to Health Information Management Systems (HIMS), This article is protected by copyright. All rights reserved.

(9) Accepted Article. i.e. paper, and electronic structures used to coordinate, deliver, and record data. Process measures included measures of nurse staffing, recruitment, and retention, as well as skills development among ICU nurses. Outcome measures included infection control quality, prevention of gastrointestinal bleeding and pressure ulcers, sepsis, central line associated bloodstream infections, ventilator acquired pneumonia (VAP), catheter-related bloodstream infections, pain management, and patient and family satisfaction with care, as well as staff outcomes such as job satisfaction. Data extraction, analysis, and synthesis. Data were extracted into a researcher-developed table. The main summary measures recorded for each study included the nursing leadership style, reported quality measures, and the reported association between nursing leadership styles and the quality measures. We also recorded the study setting, author, year, aim of the study, and methods used. Additional subgroup analysis was done based on the types of quality measures considered in the articles. These were developed after the first scan of the full text of the selected articles.. Quality assessment The methodological quality of the included articles was evaluated using two quality appraisal tools from the Joanna Briggs Institute (JBI), namely the JBI quality appraisal checklists for analytical cross-sectional studies and qualitative research (JBI, 2020) (See Supplementary information II & III). Results Study characteristics Settings: Six studies were conducted in the United States (Boyle, Bott, Hansen,. Woods, & Taunton, 1999; Bratt, Broome, Kelber, & Lostocco, 2000; Moneke & Umeh, 2013; Pollack, Koch, & NIH-District of Columbia Neonatal Network, 2003; Rouse, 2009; Vogus & Sutcliffe, 2007), and one was conducted in Australia (Linton & Farrell, 2009). Table II shows the characteristics of included studies. The studies were conducted in neonatal (n=1) (Pollack et al., 2003), pediatric (n=1) (Bratt et al., 2000) and general adult ICUs (n=5).. The study by Bratt et al. (2000) examined the largest sample of nurses working in ICUs (n=1963), followed by that of Vogus & Sutcliffe (13 ICUs). These two studies were the only ones using samples spanning multiple sites (Bratt et al., 2000; Vogus & Sutcliffe, 2007).. This article is protected by copyright. All rights reserved.

(10) Accepted Article. Summary of methodological designs: Five studies (Boyle et al., 1999; Bratt et al.,. 2000; Moneke & Umeh, 2013; Rouse, 2009; Vogus & Kathleen, 2007) used cross-sectional designs. One study (Linton & Farrel, 2009) employed a qualitative phenomenological approach, while Pollack et al (2003) used a cohort design. Linton & Farrel (2009) adopted Giorgi’s (1970) descriptive approach. In terms of a conceptual model, two studies (Boyle et al., 1999; Bratt et al., 2000) were guided by conceptual models based on literature. While three studies (Moneke & Umeh, 2013; Pollack, Koch, & NIH-District of Columbia Neonatal Network, 2003; Rouse, 2009; Vogus & Sutcliffe, 2007) reported no specific theoretical framework. Quality review summary: Three reviewers collaboratively reviewed studies using the. JBI quality appraisal tools. Supplementary appendix II and III provide a summary of quality review of included studies. Particularly, studies reported a clearly defined criteria for inclusion of participants, gave details on the nature of study participants, research settings, measured outcomes in a reliable way and used appropriate statistical analysis. Three studies (Boyle et al., 1997; Vogus & Sutcliffe, 2007; Pollack et al., 2003) were of high methodological quality because those studies received a “Yes” score for all six relevant items from the JBI checklist for analytical cross-sectional studies. Confounding variables and how they were dealt with were reported in the included studies. The other studies were of. moderate methodological quality (moderate implies that a study received “Yes” score on four of the six items used for appraisal). One study (Moneke & Umeh, 2013) was of low quality (low implies a study received a “Yes” score for only two of the six appraisal items:. Supplementary information II). The study did not report on study participants, setting, confounders and statistical analysis used. The strengths of the studies included in this review. include congruity between the methodological approaches used in the studies with objectives, stated philosophical perspective, data collection, analysis and interpretation of results. Linton and Ferral’s (2009) qualitative study clearly reported the participants’ voices and drew conclusions from analysis and interpretation of qualitative data. However, the researchers’ cultural or theoretical position in the study, influence on the research and ethical considerations were not reported thus rating the study as moderate (scores 7 out of 10 items; supplementary appendix III). Nursing leadership styles in intensive care units. This article is protected by copyright. All rights reserved.

(11) Accepted Article. The leadership styles identified included Bass and Avolio’s (1994) transformational. style, considerate leadership, Kouzes and Posner’s leadership model, and absentee leadership.. The transformational leadership theory was identified in one study (Linton & Farrel, 2009). The authors highlighted the five leadership characteristics from nurses in an adult ICU: leading by example, communication, ability to think outside the management square knowing your staff and stepping up during times of crisis. Boyle at al., (1999) indicated that higher perceived influence of the manager over how staff do their work, manager’s ability to solve problems, and control others through reward and punishment directly affects critical care nurses’ intent to stay in the job. Moneke & Umeh (2013) investigated the influence of leadership on critical care. nurses’ job satisfaction. The five practices of exemplary leadership posited in Kouzes and Posner’s leadership theory (model the way, inspire a shared vision, challenge the process, enabling others to act and encourage the heart) were investigated. Four studies (Bratt et al., 2000; Pollack et al., 2003; Rouse, 2009; Vogus & Sutcliffe,. 2007) did not highlight specific leadership theories however, they identified leaders’ characteristics. Rouse (2009) investigated nurse leaders’ participation in three aspects: communication, mentoring and planning behaviours. Absentee leaders have little or no. involvement in communication, mentoring or planning whilst incompetent leaders are perceived as inconsistent, inaccurate and confusing when participating in communication, mentoring and planning (Rouse, 2009). Bratt et al., (2000), Pollack et al., (2003) and Vogus & Sutcliffe, (2007) did not isolate. specific leadership characteristics that could be linked to a particular leadership theory. However, these studies highlight essential leadership traits. Bratt’s et al., (2000) study highlighted the elements of effective leadership such as: participative leadership, nursing leadership that is perceived as supportive, and as providing a cohesive work environment in which nurses can collaborate effectively with other health professionals, nurses find it crucial to have leaders who remove the barriers and secure for the nurses the resources needed for the provision of quality care. Pollack et al., (2003) showed that trusted leaders create a context that enhances the. effects of safety organizing on patient safety. For example; discussion on errors and ways to learn from them are supported when nurses have trust in leadership. Vogus & Sutcliffe. This article is protected by copyright. All rights reserved.

(12) Accepted Article. (2007) showed that managerial attribute such as the leaders’ fairness and integrity are linked to clinical outcomes. Impact of nursing leadership styles on quality measures in ICUs The impacts of nursing leadership styles on quality measures in ICUs were grouped. according to two types of quality measures (outcome measures, structural measures and process measures). Our literature review did not identify any published study reporting the impact of nursing leadership on process measures. Table III provides a summary of findings from included studies. The commonest category studied across studies was the impact of nursing leadership. on outcome measures. The aspects studied included the impact of nursing leadership on staff outcomes (job satisfaction, intent to stay). The relationship of nursing leadership and job satisfaction was reported in two studies (Bratt et al., 2000; Moneke & Umeh, 2013). Impact on outcome measures: Outcome measures reported across studies included. nurses’ intent to stay on job, job satisfaction, medication errors, and incidence of periventricular/intraventricular hemorrhage and periventricular leukomalacia (PIVH/PVL). Four studies discussed the relationship between leadership styles and outcome. measures. Leadership impacted job satisfaction/work satisfaction (Moneke et al., 2013; Bratt et al., 2000), medication errors (Vogus and Kathleen, 2007), and the incidence of periventricular/intraventricular hemorrhage and periventricular leukomalacia (PIVH/PVL) in neonatal intensive care units (Pollack et al., 2003). Boyle’s (1999) study revealed that the leaders’ characteristics accounted for 12% of. the variance in nurses’ intent to stay. Higher perceived manager’s influence over how nurses do their work, the manager’s ability to solve problems and utilization of reward and punishment substantially influence intent of nursing staff to stay on job (Boyle et al., 1999). Findings of Bratt’s (2000) study showed that nursing leadership that is perceived as. supportive fosters a cohesive work environment. The authors’ analysis also revealed that nursing leadership indirectly influences job satisfaction due to its importance in maintaining a. cohesive work environment. Moneke & Umeh’s (2013) study revealed that critical care nurses’ job satisfaction. revealed a positive, statistically significant relationship with the practices of exemplary. This article is protected by copyright. All rights reserved.

(13) Accepted Article. leadership (i.e leaders who model the way, inspire a shared vision, enable others to act, and leadership which challenges the process). However, Moneke & Umeh’s (2013) further analysis showed a weak significant correlation between job satisfaction and leaders who challenge the process. Vogus & Kathleen (2007) found that the trusted leadership style has a significant. positive relationship with reported medication errors in ICUs (p<0.01). Additionally, leadership among nurses in the Neonatal Intensive Care Unit (NICU) was associated with the incidence of PIVH/PVL in neonatal intensive care units (Pollack et al., 2003). Impact on structural measures: One study (Rouse, 2009) reported on the association. of leadership and structural measures. The measure reported in Rouse’s study (nurses’ productivity and morale) is related organizational resources and facility operating capacity Rouse (2009) analyzed reactions to ineffective nurse leaders’ participation in an ICU and found that absentee leadership reduces nurses’ productivity and morale, whereas active supervisor participation had positive effects on organizational outcomes. 6 DISCUSSION Leadership is crucial for delivering safe and evidence-based quality care (Kallas,. 2014). The review indicated that nurse leaders in ICUs use different leadership styles. Those who express considerate leadership, transformational and exemplary leadership practices can positively influence nursing workforce outcomes such as intent to stay and job satisfaction (Boyle et al., 1999; Rouse, 2009). Maintaining a stable cadre of ICU nurses requires reduced job stress and job satisfaction, this in turn is linked to intent to stay. Similarly, other authors have argued that nursing leadership is an essential component of the nurse-nurse interaction that strongly influences nurses’ job satisfaction (Ylitörmänen, Turunen, Mikkonen, & Kvist, 2019). Thus nursing leadership is a vital work-motivating factor that promotes occupational welfare (Ylitörmänen, Turunen, & Kvist, 2018). Exemplary leadership (Kouzes and Posner’s leadership model) and considerate. leadership were associated with higher job satisfaction (Boyle et al., 1999; Moneke & Umeh, 2013). Leadership behaviors that elicit and cherish contributions from staff promote an. environment that fosters decision making at the staff nurse level, and one where information is effectively shared. Elsewhere, transformational leadership was identified as the most beneficial leadership style in terms of its impact on healthcare staff and the working environment (Murphy, 2005). This typically enhances the ability to inspire confidence, This article is protected by copyright. All rights reserved.

(14) Accepted Article. respect, and instill a common goal or vision (Sfantou et al., 2017). Transformational leaders also improve care by embracing transformational knowledge, which is a basic component of the effective practice collection (Cook & Leathard, 2004). Examining factors associated with outcome measures is central to assessing quality of. care. One study (Vogus & Sutcliffe, 2007) included in this review indicates that leadership styles are associated with medication errors. Medication errors are a key outcome measure because they occur commonly in ICUs (Eslami, Aletayeb, Aletayeb, Kouti, & Hardani, 2019). It has also been established that fairness and integrity are important for discerning patterns in the occurrence of medication errors (Vogus & Sutcliffe, 2007). Assessing medication errors therefore requires a continual and a systematic review process that emphasizes preventing future occurrences of errors rather than punishing past occurrences; such an approach is characteristic of trusted leadership (Vogus & Sutcliffe, 2007). However, it is not yet clear how leadership styles induce changes in the incidence of medication errors. Consequently, there is a need for further study on the mechanisms by which leadership styles influence the occurrence of medication errors. Nonetheless, this review showed that trusted leadership and medication errors in ICU are positively correlated (Vogus & Sutcliffe, 2007). This can be attributed to the role leaders play in organizing and promoting a supportive environment in nursing units (Lappalainen, Härkänen, & Kvist, 2019). In particular, nurses are more likely to comply with safety precautions and behaviors if they trust their leaders. Similarly, other studies found that trusted leaders enhance safety behaviors such as probing current protocols, discussing errors, and applying methods to prevent their occurrence (Hoffer Gittell, 2002; Vogus & Sutcliffe, 2007). A notable addition to evidence on leadership contributed in this review is the. indication of trust in leadership and its association with reported medication errors. Our findings draw firmer conclusion regarding the leadership styles that are positively related with various outcome and structural measures based on the nature of included evidence. Five of the six quantitative studies (Boyle et al., 1999; Bratt et al., 2000; Rouse, 2009; Vogus & Sutcliffe, 2007) conducted multivariate statistical analyses. This is essential for establishing the extent of a model fit with empirical data and the predictive ability of variables. Thus, these studies precisely specified relationships between leadership styles and assessed quality measures. In addition, most studies were rated as high or moderate quality. The findings of this review will be useful during the training, identification, recruitment, selection, hiring, and continuous development of nurse leaders in ICUs and other settings. A key limitation of This article is protected by copyright. All rights reserved.

(15) Accepted Article. this review is that it is based on only seven studies; moreover, the studies were conducted in developed countries. This leaves a gap regarding nursing leadership from ICU contexts in low-middle income settings. Thus, indicating a clear need for further research on nursing. leadership styles and their impact on quality measures in ICUs. Implications for nursing management: The results of this review support the potential of nursing leadership practices on quality outcomes in ICUs. Nurse leaders using considerate, exemplary leadership practices, transformational and trusted leadership styles guarantee better quality of care in ICUs. Moreover, the favorable leadership styles identified in this review can be considered when training modern nurse leaders that can transform and empower the nursing profession. Organizational support and leadership training in the former leadership styles is needed to foster modern nursing leadership. This is urgently needed to meet the rising demand for quality ICU services. CONCLUSIONS This review highlighted varying leadership styles, their attributes, and their relational. impact on quality measures in ICUs. The leadership theories identified included Bass and Avolio’s transformational leadership, considerate leadership, exemplary leadership, trusted leadership, and absentee leadership. Relational patterns of nursing leadership and quality measures; structured according to the three categories of quality measures revealed important findings. Studies showed association between nursing leadership and outcome measures, and structural measures. We found little published research in this area indeed, there were no studies describing the relationship of nursing leadership and process outcomes. In addition, few studies have reported the association between nursing leadership and outcome measures, and structural measures. Much of the research that is currently available on leadership styles offers little insight into structural measures. One study reported on nursing leadership and structural outcomes, this limits the conclusions that can be drawn from a single study. Weaknesses in the seven studies included in the review are related to study designs, crosssectional designs limit interpretation of causality. More targeted studies using different designs are needed to assess the impact of leadership styles on quality measures in critical care settings.. References. This article is protected by copyright. All rights reserved.

(16) Accepted Article. Boyle, D. K., Bott, M. J., Hansen, H. E., Woods, C. Q., & Taunton, R. L. (1999). Managers’ leadership and critical care nurses' intent to stay. American Journal of Critical Care, 8(6), 361–371.. Bratt, M. M., Broome, M., Kelber, S., & Lostocco, L. (2000). Influence of stress and nursing leadership on job satisfaction of pediatric intensive care unit nurses. American Journal of Critical Care, 9(5), 307–317. doi:10.4037/ajcc2000.9.5.307. Braun, J.-P., Mende, H., Bause, H., Bloos, F., Geldner, G., Kastrup, M., … NeQuI (quality network in intensive care medicine). (2010). Quality indicators in intensive care medicine: why? Use or burden for the intensivist. German Medical Science, 8, Doc22. doi:10.3205/000111. Chen, L., Huang, L.-H., Xing, M.-Y., Feng, Z.-X., Shao, L.-W., Zhang, M.-Y., & Shao, R.-Y. (2017). Using the Delphi method to develop nursing-sensitive quality indicators for the NICU. Journal of Clinical Nursing, 26(3-4), 502–513. doi:10.1111/jocn.13474. Cook, M. J., & Leathard, H. L. (2004). Learning for clinical leadership. Journal of Nursing Management, 12(6), 436–444. doi:10.1111/j.1365-2834.2004.00420.x. Cummings, G. G., Tate, K., Lee, S., Wong, C. A., Paananen, T., Micaroni, S. P. M., & Chatterjee, G. E. (2018). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, 85, 19–60. doi:10.1016/j.ijnurstu.2018.04.016. Dimick, C. (2010). Quality check: an overview of quality measures and their uses. Journal of AHIMA, 81(9), 34–38.. Donabedian, A. (1988). The quality of care. How can it be assessed? The Journal of the American Medical Association, 260(12), 1743–1748. doi:10.1001/jama.260.12.1743. Dumitrascu, O. M., & Demaerschalk, B. M. (2017). Telestroke. Current Cardiology Reports, 19(9), 85. doi:10.1007/s11886-017-0895-1. Eslami, K., Aletayeb, F., Aletayeb, S. M. H., Kouti, L., & Hardani, A. K. (2019). Identifying medication errors in neonatal intensive care units: a two-center study. BMC Pediatrics, 19(1), 365. doi:10.1186/s12887-019-1748-4. This article is protected by copyright. All rights reserved.

(17) Accepted Article. Hoffer Gittell, J. (2002). Coordinating mechanisms in care provider groups: relational coordination as a mediator and input uncertainty as a moderator of performance effects. Management Science, 48(11), 1408–1426. doi:10.1287/mnsc.48.11.1408.268. Kallas, K. D. (2014). Profile of an excellent nurse manager: identifying and developing health care team leaders. Nursing Administration Quarterly, 38(3), 261–268. doi:10.1097/NAQ.0000000000000032. Lappalainen, M., Härkänen, M., & Kvist, T. (2019). The relationship between nurse manager’s transformational leadership style and medication safety. Scandinavian Journal of Caring Sciences. doi:10.1111/scs.12737. Laschinger, H. K. S., Wong, C. A., Cummings, G. G., & Grau, A. L. (2014). Resonant leadership and workplace empowerment: the value of positive organizational cultures in reducing workplace incivility. Nursing Economic, 32(1), 5–15, 44; quiz 16.. Lee, J., Austin, J. M., Kim, J., Miralles, P. D., Kaafarani, H. M. A., Pronovost, P. J., … Martinez, E. (2019). Developing and testing a chart abstraction tool for ICU quality measurement. American Journal of Medical Quality, 34(4), 324–330. doi:10.1177/1062860618800596. Linton, J., & Farrell, M. J. (2009). Nurses’ perceptions of leadership in an adult intensive care unit: a phenomenology study. Intensive & Critical Care Nursing, 25(2), 64–71. doi:10.1016/j.iccn.2008.11.003. McCay, R., Lyles, A. A., & Larkey, L. (2018). Nurse leadership style, nurse satisfaction, and patient satisfaction: A systematic review. Journal of Nursing Care Quality, 33(4), 361–367. doi:10.1097/NCQ.0000000000000317. Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Annals of Internal Medicine, 151(4), 264–9, W64. doi:10.7326/0003-4819-151-4200908180-00135. Moneke, N., & Umeh, O. J. (2013). How leadership behaviors impact critical care nurse job satisfaction. Nursing Management, 44(1), 53–55. doi:10.1097/01.NUMA.0000424019.83292.fa. This article is protected by copyright. All rights reserved.

(18) Accepted Article. Murphy, L. (2005). Transformational leadership: a cascading chain reaction. Journal of Nursing Management, 13(2), 128–136. doi:10.1111/j.1365-2934.2005.00458.x. Pharande, P., Lindrea, K. B., Smyth, J., Evans, M., Lui, K., & Bolisetty, S. (2018). Trends in late-onset sepsis in a neonatal intensive care unit following implementation of infection control bundle: A 15-year audit. Journal of Paediatrics and Child Health, 54(12), 1314–1320. doi:10.1111/jpc.14078. Pollack, M. M., Koch, M. A., & NIH-District of Columbia Neonatal Network. (2003). Association of outcomes with organizational characteristics of neonatal intensive care units. Critical Care Medicine, 31(6), 1620–1629. doi:10.1097/01.CCM.0000063302.76602.86. Rouse, R. A. (2009). Ineffective participation: reactions to absentee and incompetent nurse leadership in an intensive care unit. Journal of Nursing Management, 17(4), 463–473. doi:10.1111/j.1365-2834.2009.00981.x. Tønnessen, S., Christiansen, K., Hjaltadóttir, I., Leino-Kilpi, H., Scott, P. A., Suhonen, R., … Halvorsen, K. (2020). Visibility of nursing in policy documents related to health care priorities. Journal of Nursing Management. doi:10.1111/jonm.12977. Vogus, T. J., & Sutcliffe, K. M. (2007). The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. Medical Care, 45(10), 997–1002. doi:10.1097/MLR.0b013e318053674f. Whittemore, R., & Knafl, K. (2005). The integrative review: updated methodology. Journal of Advanced Nursing, 52(5), 546–553. doi:10.1111/j.1365-2648.2005.03621.x. Ylitörmänen, T., Turunen, H., & Kvist, T. (2018). Job satisfaction among registered nurses in two Scandinavian acute care hospitals. Journal of Nursing Management, 26(7), 888– 897. doi:10.1111/jonm.12620. Ylitörmänen, T., Turunen, H., Mikkonen, S., & Kvist, T. (2019). Good nurse-nurse collaboration implies high job satisfaction: A structural equation modelling approach. Nursing Open, 6(3), 998–1005. doi:10.1002/nop2.279. This article is protected by copyright. All rights reserved.

(19) Accepted Article. Table I Inclusion and Exclusion criteria Inclusion criteria. Exclusion criteria. . Research included nursing leadership styles in intensive care. Research includes leadership without. units. results related to nursing leadership or its. . Setting: intensive care units (adult and paediatric). impact on any of the ICU quality. . Primary outcomes: quantitative measures and analyses of. measures.. nursing leadership on structural, process and outcome measures in ICUs.. . Primary sources: grey literature, empirical studies. . Studies published in English language. . Years of publication 1990-2020. This article is protected by copyright. All rights reserved.

(20) Accepted Article. Table II: Characteristics of included studies. Author, year,. Aim. Design, sample & setting. country Boyle. et. al. (1999), USA. Bratt. et. al. (2000), USA. Linton. &. Farrel, (2009). Aim: To examine the direct and. Design: multicenter cross-. indirect. sectional. effects. managers’. of. nurse-. characteristics. (power,. influence. and. Primary outcome. Quality. variables. appraisal. Intent to stay. 6/6. Sample & setting: Staff nurses in ICU (n=255). leadership style) on critical care nurse’ intent to stay in the nurses’ employment positions To explore the influence of. Descriptive cross-sectional. Group. cohesion,. nurses’. design. stress,. nurse-physician. characteristics, and elements of. Sample: staff nurses in. collaboration,. work. PCCU (n=1963). leadership,. job. leadership, group cohesion, job. Tools: group judgement. satisfaction. &. stress. scale’. attributes,. environment. &. (nursing. nurse-physician. collaboration) satisfaction. unit. on of. job. nurses. in. work. scale;. satisfaction. nursing. satisfaction. job. scale;. stress scale; collaboration. (PCCU). and satisfaction about care. to. determine. stressors that are unique to. decision;. nurses working in PCCU. empowerment behaviors. To. explore. perception. 4/6. nursing. work. satisfaction. job. Pediatric critical care units and. organizational. job. leader. ICU. nurses’. Design:. qualitative. of. nursing. phenomenological. This article is protected by copyright. All rights reserved. Lived experiences of nurses’ leadership in the. 7/10.

(21) Accepted Article. Australia. leadership in an adult ICU. methodology using semi-. adult ICU.. structured interviews Sample & setting: nurses (n=6) in adult ICU. Moneke et al. To explore the influence of. Design:. online. cross-. Leadership practices:. 2/6. (2013), USA. managerial leadership on job. sectional survey. Five leadership. satisfaction of critical care. Sample & setting: nurses. practices were. nurse; nurses in MICU, CCU,. (n=137). measured: enabling. Cardiothoracic, surgical, neuro. Tool: researcher developed. others to act,. and burn unit. 65 item tool. encouraging the heart, inspiring a shared vision, challenging the process, and modelling the way. Pollack et al. Hypothesis: NICU managerial. Design:. (2003) USA. practices. cohort.. organizational processes. Sample: nurses, physicians,. and neonatal outcomes. Rouse,. 2009. (USA). Vogus. and. and. processes. organizational could. affect. outcomes of birth 500-1499g. multi-center. Managerial. practices,. 6/6. respiratory therapists and infants.. To. analyse. reactions. to. Design:. cross-sectional. ineffective leader participation. online survey,. in an ICU. Sample. setting:. mentoring. and. ICU (n=51). planning). and. supervisor inventory. (SCI) examine. benefits. of. (communication,. Employees working in the. communication. Design:. organizational outcomes (productivity. Cross-sectional. secondary. (2007) USA. leadership (trust in manager). incident reports linked to a. incident. and. care. survey. system.. on. Sample. pathways). of. factors. medication errors. analysis. &. Participants:. of. Medication. bundling safety organizing with. (use. and. morale). Kathleen,. design. 4/6. participation. &. Instrument:. To. Three forms of leader. setting: nurses. (n=1033 from 13 ICUs). Table III Summary of findings from included studies This article is protected by copyright. All rights reserved. errors. measured from a unit’s. Safety measured. reporting. organizing using. the. safety organizing scale.. 6/6.

(22) Accepted Article. Study. Leadership theory identified in the study. Relational findings. Boyle et al. Styles: considerate leadership. Leader characteristics directly accounts for. (1999), USA. Leadership style descriptions: position of power,. variance in intent to stay, specifically. structuring expectations and consideration. position of power, influence over work. Bratt. coordination et. al. (2000), USA. Style: none specific. Nursing leadership positively correlated with. Top perceived leadership practices: difficulties. 2 measures of satisfaction: organizational. with management are a stressor. work. satisfaction. and. professional. job. satisfaction:. Linton. &. Leadership style: transformational. Farrel, (2009). Leadership. by. meanings: Acting as a role model; Effective. Australia. example, communication, ability to think outside. Leadership; Leading and managing differ;. the management square, knowing your staff and. Having awareness of staff strengths and. stepping up in times of crisis. weaknesses; Stepping up. Style: Kuozes and Posner’s leadership theory. Job satisfaction correlated with four out of. Umeh (2013),. Exemplary Leadership style descriptions: Leaders. the five leadership practices. USA. who inspire a shared vision, Leaders who model. Moneke. &. style. These attributes were inter-related. Deeper. descriptions:. leading. the way, leaders who enable others to act, and leadership which challenges the process.. Pollack et al. Integrated several leadership theories. (2003) USA. Rouse,. Leadership. among. NICU. nurses. associated. was with. Periventricular/intraventricular. hemorrhage. or periventricular leukomalacia (PIVH/PVL) 2009. (USA). Vogus. Styles: absentee leadership. When nurse leaders were perceived as absent. Top assessed leadership practices: absent or. or. incompetent leaders. productivity. incompetent,. nurses. and. reported. lower. while. active. morale. supervisor participation strongly correlated with organizational outcomes and. Styles: trusted leadership. Kathleen,. Leadership. (2007) USA. integrity. style. descriptions:. Leadership fairness and. This article is protected by copyright. All rights reserved. has. a. significant. positive. relationship with reported medication errors in ICUs.

(23) Accepted Article. jonm_13151_f1.pdf. Records identified through database searching (n = 243). Additional records identified through other sources (n = 10). Screening. Records screened (n =214). Records excluded (n =184). Eligibility. Records after duplicates removed (n =214). Full-text articles assessed for eligibility (n =30). Full-text articles excluded, with reasons (n =23). Included. Identification. Figure 1 PRISMA flow diagram showing study selection. Studies included in the final synthesis (n =7). This article is protected by copyright. All rights reserved.

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