Mean renal length by gestational age.
\r\n\t2) The divergence between the levels of reliability required (twelve-9’s are not uncommon requirements) and the ability to identify or test failure modes that are increasingly unknown and unknowable
\r\n\t3) The divergence between the vulnerability of critical systems and the amount of damage that an individual ‘bad actor’ is able to inflict.
\r\n\t
\r\n\tThe book examines pioneering work to address these challenges and to ensure the timely arrival of antifragile critical systems into a world that currently sees humanity at the edge of a precipice.
The present chapter addresses the main renal anomalies. It will be structured on nine subjects made to help the reader orientate easily when facing an anomaly in everyday practice. Information regarding the moment an anomaly is visible has taken into account midrange ultrasound machines that are responsible for most of the anomaly screening.
Kidneys are visible at 12–14 weeks of gestational age, easier with transvaginal examination, and the renal architecture is seen first at 16–18 weeks. Current protocols advise documenting the presence of the normal kidneys at the second and third trimester ultrasound. A special attention must be given not to confuse them with “lying-down” adrenal structures. We recommend using both transversal and longitudinal views; coronal views are helpful in the diagnosis of the horseshoe kidneys. Color Doppler ultrasound can be used to identify the renal arteries. Normal measurements for renal length are shown in Table 1 [1]. The renal circumference to abdominal circumference is about one-third. The anterior-posterior renal pelvis is usually less than 4 mm before 22 weeks and less than 7 mm in the third trimester.
Weeks of gestation | Fetal renal mean longitudinal length (cm) (±SD) |
---|---|
16 | 1.7 (0.3) |
17 | 1.8 (0.1) |
18 | 2.0 (0.0) |
19 | 2.3 (0.3) |
20 | 2.1 (0.1) |
21 | 2.1 (0.1) |
22 | 2.4 (0.3) |
23 | 2.5 (0.3) |
24 | 2.8 (0.1) |
25 | 2.9 (0.2) |
26 | 2.8 (0.1) |
27 | 3.0 (0.1) |
28 | 3.3 (0.3) |
29 | 3.5 (0.2) |
30 | 3.4 (0.3) |
31 | 3.6 (0.1) |
32 | 3.7 (0.2) |
33 | 3.7 (0.2) |
34 | 3.8 (0.2) |
35 | 3.9 (0.3) |
36 | 4.1 (0.3) |
37 | 4.3 (0.3) |
38 | 4.2 (0.3) |
39 | 4.2 (0.2) |
40 | 4.3 (0.2) |
41 | 4.1 (0.2) |
Mean renal length by gestational age.
Definition: this chapter will address only bilateral renal agenesis, a condition defined as the absence of both kidneys which is invariably lethal.
Incidence: 1:2000–1:5000.
Pathology: it results from failure of development of the ureteric bud. The consequence for the pregnancy is Potter sequence: oligohydramnios, Potter face, clubbed hands and feet, and pulmonary hypoplasia which leads to death in the cases that reach birth [2].
Ultrasound findings: we notice severe oligohydramnios and fail to see the kidneys and the bladder. Sometimes, lying-down adrenals may be confused with kidneys in the conditions of poor visibility associated with low amniotic fluid/absence of amniotic fluid. Color Doppler interrogation fails to demonstrate the renal arteries. A small thorax is noticed, especially if we take the time to measure the heart/chest ratio.
Differential diagnosis:
PROM (patient history and the presence of kidneys and bladder point us the right diagnosis).
Severe IUGR (kidneys are present, and there are abnormal Doppler values).
Clinical facts:
Risk of chromosomal anomalies is low (though there have been described cases of trisomy 7, 10, 21, 22).
It may be part of a nonchromosomal syndrome (COF syndrome, VACTERL).
Oligohydramnios is an associated sign only after 16 weeks.
You should always examine carefully not to confuse adrenal glands with kidneys; keep in mind that adrenal arteries can also mimic renal arteries, so Doppler is not always a solution.
Bilateral agenesis is always lethal (one-third stillbirth, the rest die at birth from pulmonary hypoplasia) (Figure 1).
Renal agenesis (absence of renal arteries).
Definition: one kidney does not form resulting one present kidney and one renal artery.
Incidence: 1:1000 [2].
Pathology: failure of development of only one ureteric bud with normal development on the other side.
Ultrasound findings: we notice an empty renal fossa on axial view; this view should be completed with longitudinal and coronal views. The contralateral kidney is increased in size (>95 percentile)—compensatory hypertrophy. The use of color Doppler shows only one renal artery. Some structures may mimic the second kidney—one is the adrenal gland, and the other is the colon.
Differential diagnosis: an empty renal fossa may be present in:
Pelvic kidney.
Unilateral renal agenesis.
Crossed renal ectopia.
Horseshoe kidney (graph).
Clinical facts:
Careful scanning of the fetal abdomen (do not confuse with renal ectopia/do not confuse kidney with adrenal glands).
Isolated unilateral kidney has good prognosis and associates rarely with chromosomal anomalies (Figure 2).
Unilateral renal agenesis.
Definition: the presence of one kidney in the pelvis; the most common location for ectopic kidney.
Incidence: 1:700–1:1200 [2, 3, 4].
Pathology: the kidney forms normally but fails to ascend to the lumbar area. This normally happens between 6 and 10 weeks of gestational age.
Ultrasound findings: the first thing we notice is an empty renal fossa; careful scanning reveals the kidney adjacent to the bladder. The normally positioned kidney shows no compensatory hypertrophy. Amniotic fluid is within a normal range. The use of color Doppler can be helpful—sometimes, you can follow the renal artery to the ectopic kidney, but sometimes a pelvic kidney can have vascularization from the iliac arteries.
Differential diagnosis: empty renal fossa (see above).
Clinical facts:
Pelvic kidney should be the first thing to search in an empty renal fossa.
Visualization can sometimes be difficult due to bowel loops or interposed iliac wing.
May be associated with genital, gastrointestinal, or cardiac anomalies.
Risk of chromosomal anomalies is low and so is the risk of nonchromosomal syndromes.
May be a family group so parents should be scanned.
Vesicoureteral reflux is frequently present so postnatal ultrasound monitoring is recommended (Figure 3).
Pelvic kidney.
Definition: the kidneys are fused in their lower poles, with equal amount of renal tissue bilaterally. The fused portion may be renal parenchyma or fibrous tissue.
Incidence: 1:400.
Pathology: the fusion takes place before the ascent of the kidney which is partially impeded by the emergency of the inferior mesenteric arteries, causing also alteration of the kidneys’ axis.
Ultrasound findings: on the standard axial scan, we can see renal tissue in front of the descending aorta. On coronal sections we can see the kidneys fused in the region of the inferior poles (other variants are possible but extremely rare). We also notice a medial rotation of the inferior poles and a lower position than normal kidneys.
Differential diagnosis: includes empty renal fossa (see above), but also severe oligoamnios may suggest pathology due to lack of visibility.
Clinical facts:
It is frequently associated with hydronephrosis and genital anomalies.
33% of cases have CNS and cardiac or skeletal malformations [5].
Risk of chromosomal anomalies—horseshoe kidney may be found in fetuses with Turner’s syndrome or trisomy 18.
Risk of nonchromosomal syndrome (caudal regression syndrome, otocephaly, Oro-facial digital syndrome).
Recurrence risk—low in isolated forms.
Careful anatomy scan to exclude other anomalies.
Karyotyping should be offered (especially if other anomalies or soft markers are present).
Postnatal monitoring for vesicoureteral reflux, hydronephrosis, and urinary tract infections is recommended.
Prognosis is considered good in isolated forms (Figure 4).
Horseshoe kidney.
Definition: both kidneys are on the same side of the abdomen; a significant number (95%) are fused.
Incidence: 1:7000.
Ultrasound findings: at the anatomy scan, we notice one empty renal fossa and one abnormally large, frequently bilobed contralateral kidney. Statistically, it is more likely to find the kidney/kidneys on the right side. Color Doppler study shows two renal arteries on the same side (one in the normal position and one lower).
Differential diagnosis: empty renal fossa (see above).
Clinical facts:
May be associated with renal anomalies, spina bifida, and sacral agenesis, so attentive evaluation of the spine should be conducted.
As all renal development variants, it may be associated with infections, obstructions, and vesicoureteral reflux so postnatal monitoring is recommended.
Postnatal evaluation of genital organs—uterine anomalies may be associated.
Definition: autosomal recessive polycystic kidney disease (ARPKD) is a bilateral renal anomaly caused by a gene disorder.
Incidence: 1:20,000–1:45,000.
Pathology: the PKHD1 gene on chromosome p21 [6] is generally accepted as a primary cause though the specific mechanism is not completely understood. Mutations are specific for individual families. The anomaly is characterized by convoluted tubes and collecting ducts often associated with liver fibrosis [4].
Ultrasound findings: ARPKD is characterized by kidney enlargement (>2SD above the mean for that gestational age) [4], increased echogenicity (resulting from the interference of the microcysts) [3], absent bladder, and oligoamnios (present from 16 weeks).
Differential diagnosis:
Autosomal dominant polycystic kidney disease (ADPKD)—normal quantity of amniotic fluid and a normal bladder.
Trisomy 13 (holoprosencephaly, polydactyly, facial anomalies).
Clinical facts:
Not associated with chromosomal anomalies.
Enlarged, hyperechogenic kidneys may be present in many syndromes (Meckel-Gruber, Bardet-Biedl, Beckwith-Wiedmann, Perlman, Elejade).
Most cases are diagnosed by 24 weeks, but you must keep in mind that kidneys may look normal until 20 weeks.
ARPKD is classified in perinatal, neonatal, infantile, and juvenile form.
Cases diagnosed in utero end with stillbirth or neonatal death.
Thirty to fifty percent die in the neonatal period.
Juvenile form has less renal involvement but marked hepatic fibrosis.
Survivors develop systemic hypertension (75%) and portal hypertension (44%).
Recurrence risk is 25%.
When diagnosed prenatally, termination should be offered (Figure 5).
Autosomal recessive polycystic kidney disease.
Definition: Multicystic dysplastic kidney (MCDK) presents with unilateral/bilateral enlarged kidneys with parenchyma replaced by multiple, noncommunicating cysts [3].
Incidence: 1:1000–1:5000; more common in males (2:1), but females have a worse prognosis (twice more likely to have bilateral forms and four times more likely to have aneuploidy).
Pathology: in normal kidney embryology, the ureteric bud signals the metanephros to form nephrons. Early ureter obstruction or atresia prevents the signaling so the metanephric tissue does not form nephrons, resulting in dysplastic cystic tissue. Segmental/partial MCDK may result from a duplex ureter [2].
Ultrasound findings:
Unilateral (75–80%): the diagnostic is made in the presence of multiple cyst structure in the renal fossa, significantly larger than normal kidneys. The bladder is normal. Amniotic fluid is within the normal range [3].
Bilateral (20%): both kidneys are multicystic; the bladder cannot be visualized, and severe oligoamnios is associated.
Partial (rare): in rare cases of duplex kidney, only part of the kidney may be involved, more frequently the superior pole.
Differential diagnosis:
Hydronephrosis (distended calyces appear as cysts, but at attentive scrutiny communication with the renal pelvis can be proved).
Obstructive cystic dysplasia (more normal renal tissue visible).
Ureteral dilatation.
Clinical facts:
Risk of chromosomal anomalies is relatively low in unilateral forms (2–4%).
The risk for nonchromosomal syndromes is about 5–10% (branchio-oto-renal syndrome, cerebro-reno-digital syndrome, VACTERL).
Careful examination of the contralateral kidney (40% have an associated anomaly).
Genetic counseling and karyotyping are advised if associated anomalies are present.
Antenatal kidney monitoring is recommended.
Conservative management is standard as most cases involute in the first years of life.
Postnatal ultrasound evaluation is recommended every 6 months (Figure 6).
Multicystic kidney (unilateral).
Definition: ADPKD is a bilateral renal anomaly where cysts arise from all areas of the nephron or collecting ducts. It commonly appears in adults but can rarely be seen prenatally, especially when screening is targeted to families at risk.
Incidence: 1:1000.
Pathology: the genetic mechanism involves two genes PKD1 and PKD2 on chromosome 16. The condition is associated with multiple renal cysts, hypertension, and renal failure. Cysts are also present in the liver, spleen, and pancreas.
Ultrasound findings: the kidneys are hyperechoic, in some cases only in the cortical region. Amniotic fluid and the bladder are usually normal.
Differential diagnosis: ARPKD (autosomal recessive polycystic kidney disease). Normal fluid, bladder, and family history help us make the difference.
Clinical facts:
Once diagnosed, serial monitoring is recommended.
Examination of parent’s kidneys is indicated due to the autosomal dominant nature of the disease.
The disease manifests in the third to fifth decade, most patients needing dialysis and transplant.
Normal ultrasound cannot exclude the disease later in life!
Definition: obstructive cystic dysplasia results from early and severe obstruction of the collecting system causing the formation of renal cysts [5].
Pathology: most cases result from early urethral obstruction, but vesicourethral junction obstruction and upper urinary tract obstruction are also a possible cause. Obstruction leads to ascension of fluid in the upper tract, with fluid retention in the nephron, with secondary cyst formation, and with a decrease in the number of normal nephrons.
Ultrasound findings: sonographic examination reveals renal macrocysts and signs of urinary tract obstruction (hydronephrosis, hydroureter, bladder distension). In cases of urethral obstruction, thickening of the bladder wall and severe oligoamnios are met.
Differential diagnosis:
MCDK.
Hydronephrosis.
ARPKD.
Clinical facts:
Risk of chromosomal anomalies (5–10%).
Risk of nonchromosomal syndromes may be found in VACTERL, cerebro-reno-digital syndrome, and tuberous sclerosis.
Look for renal cysts when urinary tract obstruction is diagnosed.
Unilateral: renal cysts + hydronephrosis/hydroureter.
Bilateral: oligoamnios + distended bladder + bilateral renal cysts.
Perform careful follow-up.
Amniocentesis is indicated when associated anomalies are present.
May be impossible to differentiate from MCDK.
Termination should be offered for bilateral form.
Definition: the dilatation of the pelvis is the most common anomaly detected by ultrasound. It can present as a mild pelviectasis or as hydronephrosis. Though numbers may vary in different sources, generally values are around these figures:
Mild pelviectasis [2]: above 4 mm in the second trimester and above 7 mm in the third trimester.
Hydronephrosis [4]: above 7 mm between 16 and 20 weeks and above 10 mm after 20 weeks.
Limits of normal size for gestational age have also been described [2]:
3 mm in the first trimester.
4 mm between 14 and 22 weeks.
5 mm between 22 and 32 weeks.
7 mm after 32 weeks.
Above 10 mm always pathology.
Incidence: 1–5:500 newborns.
Pathology: mild pelviectasis has been associated with aneuploidy (minor marker), especially trisomy 21. The mechanism for unilateral hydronephrosis may be obstruction of the ureteropelvic junction, vesicoureteral reflux, and obstruction of the vesicourethral junction. Bilateral hydronephrosis may be caused by bilateral vesicoureteral reflux or by urethral obstruction.
Ultrasound findings: renal scanning reveals a dilated renal pelvis above the cutoff for the respective gestational age. Frequently, when hydronephrosis is installed, the calyces are also dilated. Sometimes, the dilatation is isolated (as in ureteropelvic junction stenosis) or includes dilatation of the ureters. In rare cases dilatation may lead to urinoma (only in cases of severe obstruction). Amniotic fluid is usually normal and in one-third of the cases may even be increased (impaired concentration ability).
Clinical facts:
Risk of chromosomal anomalies is low, though mild pelviectasis has been associated with trisomy 21.
Risk of nonchromosomal syndromes (VACTERL, Schinzel-Giedion syndrome, camptomelic dysplasia).
In the presence of mild pelviectasis, screening for T21 markers is recommended.
Eighty percent of mild pelviectasis resolve antenatally, and half of the rest resolve postnatally [2].
Pelviectasis that is slowly progressing to hydronephrosis usually has an underlying pathology that would have to be addressed postnatally.
Even with hydronephrosis the prognosis is excellent if there is no renal impairment.
Poor prognosis may appear in cases of bilateral renal pathology or associated anomalies (syndromic or not).
Postnatal following is recommended with scans and evaluation of the renal function.
Prenatal intervention is rarely needed (Figure 7).
Bilateral hydronephrosis.
Definition: renal tumors in the fetus are more commonly mesoblastic nephroma (a benign tumor) with rare occurrence of Wilms’ tumor (which is malignant).
Pathology: mesoblastic nephroma is a benign mesenchymal tumor with spindle-shaped cells. It is frequently associated with polyhydramnios through mechanisms that are not yet fully understood; polyuria caused by hypercalcemia and bowel obstruction by mass effect are among the most accepted theories.
Ultrasound findings: examination usually reveals a tumor/mass that occupies part or the entire kidney. Mesoblastic nephromas have ill-defined margins and may present on color Doppler ultrasound as a vascular mass. When there are arteriovenous shunts, fetus may present hydrops.
Differential diagnosis:
Adrenal mass (tumor or hemorrhage).
Crossed fused ectopia.
Renal collecting system duplication.
Clinical facts:
Risk of chromosomal anomalies is very low.
Risk of nonchromosomal anomalies: Wilms’ tumor may be associated with Beckwith-Wiedemann or Denys-Drash syndrome [5].
The first sign may be polyhydramnios.
Tumor may have rapid growth.
You should look for Beckwith-Wiedmann signs.
May have a–v shunts and hydrops, or cardiac failure may appear.
Surgical removal of the tumor or nephrectomy is indicated in the neonatal period (Figure 8).
Nephroblastoma.
Nonchromosomal syndromes associated with abnormal kidneys on ultrasound that have been mentioned throughout this chapter have been included in Table 2.
Syndrome | Short description of the syndrome |
---|---|
COF skeletal syndrome | Renal agenesis + microcephaly, micrognathia, and joint contractures |
VACTERL | Renal agenesis + vertebral anomalies, anal atresia, CHD, tracheoesophageal fistula, and limb anomalies |
Meckel-Gruber syndrome | Polycystic kidney + cephalocele, microcephaly, and polydactyly |
Bardet-Biedl syndrome | Polycystic kidney + polydactyly and genital anomalies |
Beckwith-Wiedmann syndrome | Polycystic kidney + macroglossia, omphalocele, and hemihypertrophy |
Perlman syndrome | Polycystic kidney + diaphragmatic hernia, macrosomia, cleft palate, and dextrocardia |
Elejade syndrome | Polycystic kidney + omphalocele, corpus callosum agenesis, macrosomia, craniosynostosis, and skeletal dysplasia |
Brachio-oto-renal syndrome | Multicystic kidney + preauricular tags and brachial cleft fistulas |
Cerebro-reno-digital syndrome | Multicystic kidney + digital and limb anomalies and CNS malformations |
Schinzel-Giedion syndrome | Hydronephrosis + midface retraction, skull anomalies, talipes, and cardiac anomalies |
Camptomelic dysplasia | Hydronephrosis + bowed tibiae/femurs, scapular hypoplasia, micrognathia, and sex reversal in males |
Denis-Drash syndrome | Nephroblastoma + ambiguous genitalia and diaphragmatic hernia (rare) |
Nonchromosomal syndromes associated with renal anomalies.
“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 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 [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 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 [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 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 practices 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].
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 reduction, job satisfaction, increased productivity, effective work, and positive patient outcomes [10].
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 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 [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.
Resonance leadership is based on emotional intelligence and awareness, including 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.
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].
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 [17].
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 [10]. Task-focused leadership is significantly associated with high-level patient satisfaction [18].
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 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 [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 performance, especially among followers and leaders [29]. While transformational leadership 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 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 [32]. 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 [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 disobedience 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 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 [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.
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 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 [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 necessary, 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 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 [40]. 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 [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 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.
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 [45]. 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 [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, instrumental, success-oriented, and supporting leadership, respectively [34].
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 development. 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 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, 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.
The authors declare no conflict of interest.
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