The Critical Need for Leadership in Nursing

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Leadership is an imperative in today’s health care environment. Nursing leadership is needed at every level and across all settings, a 2010 study by the Robert Wood Foundation concluded. The study called for a “style of leadership that involves working with others as full partners in a context of mutual respect and collaboration.”

Nurse managers have a variety of leadership styles.And like scrubs, leadership styles are not one-size-fits-all. Effective nursing leaders rely on a mixture of styles, depending on the situation.

The Hay Group surveyed over a thousand nurses in 25 health care systems across the United States and found the managers at the top-performing nursing units employed a broader range of leadership styles. The effective leaders “spent more time creating a vision for the group and gaining buy-in, were more democratic and tried to maintain harmony through an affiliative style of leadership.”

Types of leadership styles in nursing

Leadership theorists typically categorize nursing leadership styles into two categories: transactional and transformational.

Transactional leaders are most effective in crisis situations or for projects that need to be carried out in a specific way.

  • Seek to motivate employees through reward and punishment.
  • Are more concerned with increasing the efficiency of established routines and procedures and following rules within an organization rather than making changes.
  • Are often seen in health care organizations.
  •  Nurse managers may find success with this style when leading lower-skilled workers.
  • Thwart creativity and innovation with higher-skilled workers.

Transformational leaders are more complex, but are also more effective in enhancing the morale and performance of employees and driving change within an organization.

  • Explain the “how” and “why” of hospital procedures in addition to helping nurses understand the facility’s vision.
  • Trust others, are honest and act responsibly.
  • Lead by example and inspire others to perform at higher standards.
  • Are effective communicators and motivators who focus on team-building and collaboration among employees and encourage innovation and creative thinking.

Applying the transactional style in nursing

Transactional leaders give orders, expecting followers to comply. This style is most effective during a crisis or when managing lower-skilled workers who require closer supervision.


  • Best style to use during an actual emergency.
  • Provides clear direction for new nursing graduates.
  • Can work with nurses who have poor performance.


  • Employees can feel that their opinions are not valued.
  • Can condition employees to be more passive.
  • Can create a climate of fear.

Applying the transformational style in nursing

Leadership author Daniel Goleman studied the effective leadership of 20,000 executives worldwide and identified four distinct substyles within the transformational leadership umbrella: authoritative, democratic, affiliative and coaching.

“I may not be the most knowledgeable person…but I know how to get people to think well about themselves.”
Joyce Clifford, former nurse-in-chief at Beth Israel Deaconess Medical Center

Authoritative leadership

Authoritative leaders mobilize people toward a vision and, according to Goleman, are considered the most effective overall leadership style. This leader paints a vivid picture of an end goal and motivates people by showing how their work fits in with the larger vision. The employees are given latitude on how to achieve the vision.

Authoritative leadership is not to be confused with authoritarian or autocratic leadership.


  • Effective when a clear direction or a turnaround is needed.
  • People who work for these leaders understand that what they do matters and why.


  • This style can be seen as overbearing.

Democratic leadership

Democratic leaders seek input from employees and, as a result, build consensus through participation. Also known as participative leaders, this style encourages participation from everyone, but the leader has the final say in the end decision. This leadership style is best used when a leader is unsure about next steps and needs ideas from others.

Connie Hill, MSN, RN, director of a 30-bed unit at Children’s Memorial Hospital in Chicago, sought to provide a venue where nurses had more of a voice in patient care and in communicating with families. Hill created a system that improved communication between nurses and the rotating medical residents, resulting in improved patient care. Her democratic leadership style allowed more nurses to have a voice in their roles.


  • Employees feel that their opinions are heard.
  • Builds morale.
  • May reduce the amount of workplace bullying and disruptive behavior.


  • This approach takes more time, and there can be endless meetings.
  • Can appear as if the nurse manager is not in charge.

Affiliative leadership

Affiliative leaders seek to form emotional bonds with followers by offering positive feedback and creating a sense of belonging. This style is effective when trying to build team harmony, increase morale or repair broken trust. According to Goleman, this style works best in conjunction with the authoritative style.


  • Effective in restoring trust and boosting morale.
  • Improves communication among team members.


  • This style should not be used exclusively.
  • Can allow poor performance to go uncorrected.

Coaching leadership

Coaching leaders focus on developing people for the future. They help employees identify their strengths and weaknesses, set development goals and help plan how to achieve them. This leader is concerned with employees’ personal and career aspirations and achieving personal growth.

An example of a coaching style would be nursing pioneer Imogene King’s theory on goal attainment. King emphasized the importance of nurses setting goals with patients instead of planning their care without patient involvement.


  • Helps employees develop personally and professionally.
  • Delivers results for the long term.


  • Is time intensive, especially in the beginning.
  • Works only when an employee is receptive.

What leadership style works best for nurses?

Evidence-based research suggests transformational leadership in health care enhances nurse satisfaction, promotes a positive work environment and reduces staff turnover. And the Institute of Medicine has identified transformational leadership as a crucial element to implementing a change initiative or toward achieving work environments that optimize patient safety.

Joyce Clifford, a nurse executive at Beth Israel Deaconess Medical Center, was a transformational leader. Clifford advocated a partnership of equals between doctors and nurses in the treatment of patients, and her ideas were adopted in some of the nation’s largest hospitals because they reduced medical errors and improved survival rates.

Clifford credited her success to building relationships with patients, physicians and colleagues from other disciplines. “Relationships are central to success,” Clifford says.

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