Recent 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. Leadership in health services is important for following innovations 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 determinant of job satisfaction and persistence of nurses. The need for nurses with leadership 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.
- leadership styles
- patient safety
- quality of care
“Leadership is not only about individuals, but also about teams” .
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 . 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 . The inclusion of complex technology and intense human relations in hospital services, which constitute a significant part of health care services, leads to the emergence of important managerial problems . 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 determine 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 . 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 directs the members of the group in line with these goals . 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 practices on patient outcomes and patient safety, health service power and corporate culture were determined . However, Cummings  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 .
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 . These leadership styles are associated with increased employee satisfaction, organizational commitment, improved staff health and well-being, stress reduction, job satisfaction, increased productivity, effective work, and positive patient outcomes .
2.1.1 Transformational leadership
Transformational leadership is considered the gold standard of leadership . 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 . 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 .
It is thought that the transformational leaders fascinate their audience with the charisma feature. This fascination is sometimes associated with the physical characteristics of the leader as well as communication skills and vision. The inspiring character of transformational leaders supports and motivates their followers with encouraging speeches in case of hard work and crises .
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 . 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, including being open and sensitive to judgment . Resonance leaders have emotional intelligence features. These are self-awareness, self-management, social awareness, and relationship management . 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 .
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 importance in the decision-making process, with a wide range of expertise and participation 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 .
2.2 Task-focused leadership
The task-focused leadership style involves planning business activities, clarifying 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 . Task-focused leadership is significantly associated with high-level patient satisfaction .
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 . Leaders in transactional 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 . 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 . 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 .
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 . Bass emphasizes the use of interactive leadership as a conditionally rewarding performance, especially among followers and leaders . While transformational leadership results in a performance beyond expected, interactive leadership focuses on the expected results . 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 .
Another type of transactional leadership is autocratic leadership. Autocratic leaders 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 . The autocratic leadership style can be considered ideal in emergencies because he or she takes all decisions himself/herself, regardless of the views of the leading staff . 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 disobedience is punished [18, 32]. In addition, autocratic leaders can create fear among staff and often make decisions without consulting the team . 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 transformed into appreciation and devotion when the positive results of their leadership 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 followers 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 . 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 , 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. . 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 . The main task of the leader is to provide resources. Such leaders dissipate responsibilities and retreat and refrain from taking decisions . 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 .
Leadership that recognizes full freedom is an authoritative, task-focused leadership 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 . 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 . 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 necessary, he/she creates a group with the people he/she wants, solves the problems, tries new ideas, and reaches the most appropriate decisions . 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 organizational 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 . Hinkin et al. also state that leadership behaviors that recognize full liberty harm the punitive and rewarding roles of the leader and decrease leaders’ effectiveness . Chaudhry and Javed state that fully free leadership has no effect on the motivation of the followers compared to other types of leadership . Şentürk et al. reveals that fully free leadership does not have a reinforcing effect on innovative behaviors but rather reduces it . 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 . 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 corporate performance [43, 44]. This leadership style is part of the spectrum of transformational 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 . In current leadership approaches, the strategy and task-focused developmental functions 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 harmony between the organization and the environment, developing strategies, preparing task and strategy tables, using resources effectively, and providing performance feedback . The most prominent feature of the instrumental leadership type is the determination of the subordinates’ path by the leader . 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 . Akyurt et al. found that instrumental and interactive leadership have a statistically significant and positive effect on job satisfaction and organizational commitment . 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, instrumental, success-oriented, and supporting leadership, respectively .
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 . 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 . Leadership is important for every organization as well as for health organizations, because the success of an organization is a good leader . For effective leadership, it is important to focus on the dynamic relationships between guidance, leadership values, culture, talent, and organizational context . 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 development. Leaders make the voice of patients continuous; they continuously monitor their patient experiences, concerns, needs, and feedback . Nurses, the largest workforce in a health institution and a dynamic profession, play an important role in health leadership and policy-making, while maintaining their traditional care skills . 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, 52, 53]. In addition, effective leadership styles can increase the quality of health care outcomes. In addition, leadership in health facilities is considered as an important factor in ensuring quality health services, patient satisfaction, and financial performance.
Nurses are responsible for guiding the community because of their responsibilities in health care. Patient care and education, effective communication, and clinical management are the most important tasks. These tasks are closely related to leadership 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 implementation 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.
We thank everyone who provided scientific guidance.
Conflict of interest
The authors declare no conflict of interest.