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3 AUTHORS, INCLUDING:
1 2 3
CAROL A. WONG PhD, RN , GRETA G. CUMMINGS PhD, RN, FCAHS and LISA DUCHARME BScN, RN, MN
1
Associate Professor, Ontario Ministry of Health and Long-Term Care Nursing Early Career Research Award
Recipient, Arthur Labatt Family School of Nursing, Faculty of Health Sciences, Health Sciences Addition (HSA),
The University of Western Ontario, London, Ontario, 2Professor, Faculty of Nursing, Edmonton Clinic Health
Academy, University of Alberta, Edmonton, Alberta and 3Practice Consultant, Nursing Professional Scholarly
Practice, London Health Sciences Centre (LHSC), London, Ontario, Canada
Correspondence WONG C.A., CUMMINGS G.G. & DUCHARME L (2013) Journal of Nursing Management
Carol A. Wong 21, 709724.
Arthur Labatt Family School of The relationship between nursing leadership and patient outcomes: a
Nursing systematic review update
Faculty of Health Sciences
Room H27, Health Sciences Aim Our aim was to describe the findings of a systematic review of studies that
Addition (HSA) examine the relationship between nursing leadership practices and patient
The University of Western outcomes.
Ontario
Background As healthcare faces an economic downturn, stressful work
1151 Richmond Street
environments, upcoming retirements of leaders and projected workforce
London
shortages, implementing strategies to ensure effective leadership and optimal
Ontario N6A 5C1
patient outcomes are paramount. However, a gap still exists in what is known
Canada
about the association between nursing leadership and patient outcomes.
E-mail: cwong2@uwo.ca
Methods Published English-only research articles that examined leadership
practices of nurses in formal leadership positions and patient outcomes were
selected from eight online bibliographic databases. Quality assessments, data
extraction and analysis were completed on all included studies.
Results A total of 20 studies satisfied our inclusion criteria and were retained.
Current evidence suggests relationships between positive relational leadership
styles and higher patient satisfaction and lower patient mortality, medication
errors, restraint use and hospital-acquired infections.
Conclusions The findings document evidence of a positive relationship between
relational leadership and a variety of patient outcomes, although future testing of
leadership models that examine the mechanisms of influence on outcomes is
warranted.
Implications for nursing management Efforts by organisations and individuals to
develop transformational and relational leadership reinforces organisational
strategies to improve patient outcomes.
Keywords: nursing leadership, patient outcomes, systematic review
DOI: 10.1111/jonm.12116
2013 John Wiley & Sons Ltd 709
C. A. Wong et al.
2002, 2008, Needleman et al. 2002, Tourangeau et al. setting factors, (2) process which is concerned with
2002, Cho et al. 2003, McGillis Hall et al. 2003, mechanisms for coordinating and facilitating patient
Estabrooks et al. 2005, Blegen et al. 2011). However, care and (3) outcomes of care. Originally described as
there is less research examining other work environ- a framework for conceptualising the dimensions of
ment factors, specifically, nursing leadership and its health care practice, Donabedian (1966) postulated
effects on patient outcomes. that each of these core dimensions was a necessary
Effective nurse leaders ensure that appropriate staff- condition for the one that followed. Structures influ-
ing and other resources are in place to achieve safe ence processes and processes influence outcomes. The
care and optimal patient outcomes. At the organisa- SPO framework has been used extensively in examin-
tional level senior nurse executives contribute to stra- ing relationships among organisational structural fea-
tegic directions through their participation in senior tures such as nurse staffing (Cho 2001, McGillis-Hall
level decision-making and their ability to influence & Doran 2007) or leadership (MacPhee et al. 2010)
how nursing is practised and valued (Huston 2008, and nurse (MacPhee et al. 2010) and patient outcomes
Wong et al. 2010). At the department and unit levels, (Cho 2001, McGillis-Hall & Doran 2007). In this
frontline leaders engage nurses in decision-making review we describe the SPO framework to examine the
about patient flow and staffing, quality improvement linkages between leadership and patient outcomes.
activities, and continuous learning opportunities to We isolated the leadership style of nurse leaders in
improve overall care delivery (Page 2004, Tregunno organisations as structure. Leadership was defined
et al. 2009, Thompson et al. 2011). The current eco- broadly as the process through which an individual
nomic downturn, health and safety concerns associ- attempts to intentionally influence another individual
ated with stressful work environments, more leaders or a group in order to accomplish a goal (Shortell &
nearing retirement, and projected workforce shortages Kaluzny 2000, p. 109). We further categorised leader-
are testing the abilities of healthcare leaders in sustain- ship as either relational or task-oriented. Cummings
ing, let alone improving, the level of patient care. In et al. (2010a) explained that leadership styles may be
the challenge for organisations to make practices more broadly characterised as approaches that focus on peo-
cost-effective yet improve outcomes, attract and retain ple and relationships (relationally oriented) to achieve
high-performing staff, and be more responsive to common goals or as styles that focus on structures and
patient needs, effective nursing leadership is critical to tasks (task-oriented). Leaders differ in the extent to
advance agendas for change (Page 2004, Lowe 2005, which they pursue a human relations approach and
Fine et al. 2009). show concern and respect for followers, express appre-
The purpose of this study was to describe the find- ciation and support, and are genuinely concerned for
ings of a systematic review of studies in the literature their welfare (Bass & Stogdill 1990). For example,
that examine the relationship between nursing leader- transformational leadership is a relational leadership
ship practices and patient outcomes. In a previous style in which followers have trust and respect for the
review, we searched electronic databases for the leader and are motivated to go above and beyond nor-
20 years between 1985 and 30 April 2005 and found mal work expectations to achieve organisational goals
only seven studies examining the relationship between (Bass 1985, Bass & Avolio 1994).
nursing leadership and patient outcomes (Wong & Leaders also differ in their attention or focus on the
Cummings 2007). In this review, we updated the evi- groups goals and the means to achieve those goals
dence by adding the results of studies published (Bass & Stogdill 1990). Those with a strong task ori-
between 1 May 2005 and 31 July 2012 to the evi- entation define and organise the roles of followers, are
dence reported in the previous paper and reviewed the concerned with goals, procedures and production,
body of research on the relationship between nursing establish well-defined lines of communication, and are
leadership and patient outcomes. likely to keep their distance psychologically from their
followers (Bass & Stogdill 1990). An example of a
task-oriented style is transactional leadership that
Conceptual framework
emphasises the transaction or economic exchange that
A conceptual framework for the study review was takes place among leaders, colleagues and followers to
developed based on Donabedians (1966) structure accomplish work (Bass & Avolio 1994). The transac-
processoutcome (SPO) framework (see Figure 1). tional leaders role is primarily that of recognising
Three conceptual domains comprise this framework: follower needs and monitoring their role fulfilment
(1) structure which is concerned with organisational or (Bass 1985, Bono & Judge 2004).
Figure 1
Framework for systematic review
(Donabedian 1966).
The process concept in our framework was defined examined the association between leadership and
as the leadership processes or mechanisms by which patient outcomes reported as direct observation of
leaders may contribute to patient outcomes. Examples patient outcomes or extracted from administrative
of these processes may include facilitating work condi- databases. Studies of nurse- or staff-reported patient
tions that promote optimum safe patient care, creating outcomes were excluded. There was no restriction on
open communication with staff to support quality care study design and published English-only articles were
standards, or promoting positive relationships with reviewed. We also required that the relationship
staff that promote work engagement (Cummings et al. between leadership and patient outcomes(s) be
2010a). expressed quantitatively and tested statistically.
Outcome considers the measurable results of care
and we focused exclusively on patient outcomes.
Search strategy and data sources
Patient outcomes were defined as outcomes describing
patient mortality, patient safety outcomes such as the We searched the following eight online bibliographic
incidence of adverse events involving patients (e.g. databases for the period 1 May 2005 to 31 July 2012:
falls, nosocomial infections) or complications during ABI Inform Dateline, Academic Search Complete,
hospitalisation, patient perceptions of satisfaction with Cochrane Database of Systematic Reviews (CDSR),
care, and healthcare utilisation such as length of stay MEDLINE, CINAHL, EMBASE, ERIC and PsychI-
(Doran & Pringle 2011). NFO. Table 1 includes a summary of the search strat-
egy. Some of the databases have changed since the
previous review, however, we were careful to include
Methods all the same sources as in the last review. We also
hand searched the journals, Journal of Nursing Man-
Inclusion criteria for studies
agement, Nursing Research, Nursing Leadership, The
Following the same inclusion criteria used in the pre- Leadership Quarterly, Journal of Nursing Administra-
vious review, we included research studies that exam- tion and Journal of Organizational Behavior as well
ined the relationship between nursing leadership in all as the bibliographies of articles identified for inclusion
types of health care settings and one or more patient in the review. As in the last review we searched
outcomes. Leadership or aspects of leadership includ- research websites for relevant research reports.
ing leadership styles, behaviours, competencies, or
practices were measured as self-reported by leaders,
Study identification and quality review
direct observation of leaders or ratings of leader
behaviours made by followers. A leader was defined The primary author and a research assistant screened
as a nurse in a formal leadership role at any level in a the titles and abstracts of the articles identified by the
health care organisation (e.g. first line, middle and/or search strategy. Articles that potentially met our inclu-
senior leadership/management roles) and who super- sion criteria, and where there was insufficient informa-
vises other nurses. Studies of clinical leadership in tion to make a decision regarding inclusion, were
staff nurses, evaluation of leadership development retrieved and assessed for relevance by the primary
programmes or the testing of leadership instruments author and a research assistant. To assess the method-
were excluded. We included only those studies that ological quality of the final set of articles, we used the
Table 1
Literature search: electronic databases
of effects on patients, significant and non-significant conducted in the United States, the others being con-
results, discussion and recommendations. Appendix S1 ducted in Canada (n = 4) and Norway (n = 1). The
includes data extraction for the 13 studies retained in studies represented a variety of care settings: inpatient
this updated review along with the data from the acute care units of hospitals (n = 12), nursing homes
seven studies identified in the previous review. (n = 4), dialysis facilities (n = 1), emergency units
Using content analysis and the conceptual frame- (n = 1), home healthcare agencies (n = 1) and neonatal
work as a guide, leadership was categorised as rela- intensive care (n = 1). The findings were combined
tionship or task-oriented and patient outcomes were despite the variety of settings. The study samples repre-
sorted into thematic categories based on their com- sented nurses (n = 10), nurses and managers (n = 6), a
mon characteristics and our previously defined out- cross-section of healthcare professionals including
come categories (Doran & Pringle 2011). Second, nurses (n = 2), a combination of nurses, auxiliary
within each thematic category we identified the pat- nurses and unlicensed care staff (n = 1) and directors of
tern of relationships between relational or task nursing (n = 1). Further details on the characteristics of
focused styles of leadership and changes in specific all 20 included studies can be found in Appendix S1.
patient outcomes. For example, we looked at which
leadership styles were predominantly associated with
Methodological quality of included studies
specific outcomes such as patient satisfaction and if
patient satisfaction increased or decreased as a result The methodological quality of the included articles is
of leadership style. We then analysed the reported summarised in Table 2. All articles used a cross-sec-
relationships between the specific leadership styles or tional design and of the 20 included articles,
practices and the outcomes by category and signifi- 17 (85%) were rated as strong and 3 (15%) as moder-
cance (P < 0.05). We also reviewed studies for the ate. Strengths of the studies included the fact that the
processes by which leadership influenced outcomes majority (n = 19, 95%) used reliable and valid mea-
that were either tested or discussed in studies and or- sures, were multi-sited studies (n = 15, 75%), had
ganised into themes based on common characteristics. acceptable sample sizes (n = 17, 85%) and reported
correlations of multiple effects (n = 18, 90%). In all
but one study, leadership was measured by asking
Results followers to rate the leadership style of their formal
leader. Observed leadership behaviours assessed by a
Description of studies
leaders followers contributes to the construct validity
Article selection for this review is summarised in of the measurement of leadership more effectively
Figure 2. Database and hand searches yielded 20 383 than leader self-report (Dunham 2000, Xin & Pelled
titles/abstracts and of these, 121 were identified as 2003), because self-report measures are subject to
potentially relevant after title and abstract review. social desirability response bias (Polit & Beck 2011).
One of the 121 studies was a published journal article Six (30%) studies used only self-report measures for
(McCutcheon et al. 2009) of one of the retained seven patient outcomes, specifically satisfaction with care.
studies in our previous review (Doran et al. 2004) All other patient outcome measures were collected
which we obtained as a research report from a prospectively in the study or extracted from adminis-
research website. We excluded that article plus 107 trative databases. Eighteen (90%) studies reported
others, leaving only 13 studies meeting our selection using multivariate analysis including multiple regres-
criteria after article reviews. sion, logistic regression, hierarchical linear modelling
We added these 13 articles to the seven articles (HLM), or structural equation modelling (SEM). The
retained in our previously reported systematic review unit of analysis for leadership and patient outcomes
(Wong & Cummings 2007) and described the charac- was the unit/organisational level in 17 studies.
teristics of all 20 included studies. These articles repre- Weaknesses of studies identified in the quality
sent 20 original studies with the exception of the assessment related mainly to sample representative-
Capuano et al. (2005) paper which built on the Houser ness, treatment of outliers, explicit inclusion of a con-
(2003) study by using the same conceptual model, col- ceptual or theoretical framework, response rates and
lecting data on the same variables in another setting reporting study reliabilities for measures used. Only
and then adding the data to the Houser (2003) database five (10%) of studies reported using random sampling
and re-tested the model. All 20 studies were published and 12 (60%) had response rates less than 60%. Six
between 1999 and July 2012 and all but five were (60%) addressed outliers in their data, while seven
Table 3
Summary of study outcomes: relationship between leadership and patient outcomes
Patient satisfaction Doran et al. (2004) Increased Transactional leadership style (R)
Larrabee et al. (2004) NS Transformational leadership (R)
McNeese-Smith (1999) Increased Transformational leadership practices (R)
Gardner et al. (2007) NS Manager ability and support (R)
Kroposki & Alexander (2006) Increased Supervisors work collaboratively with staff (R)
Raup (2008) NS Transformational leadership (R)
Havig et al. (2011) Increased Task-oriented leadership (T)
Patient mortality Houser (2003) Decreased Transformational leadership practices through
increased staff expertise and stability (R)
Pollack and Koch (2003) NS Higher leadership (only respiratory therapists
ratings were significant (R) &(T)
Boyle (2004) NS Inverse association with manager ability
and support (R)
Capuano et al. (2005) Decreased Transformational leadership practices
through increased staff expertise (R)
Cummings et al. (2010b) Decreased High resonant leadership (R)
Tourangeau et al. (2007) Increased Manager ability and support (R)
Patient safety:
(a) Adverse events
Behaviour problems Anderson et al. (2003) Decreased Participative leadership (R)
Restraint use Anderson et al. (2003) Decreased Communication openness (R)
Castle & Decker (2011) Decreased Consensus leadership (R)
Complications of Anderson et al. (2003) Decreased Relationship-oriented leadership and less
immobility formalisation (R)
Fractures Anderson et al. (2003) Decreased Relationship-oriented leadership (R)
Medication errors Houser (2003) Decreased Transformational leadership practices
through increased staff expertise and
stability (R)
Boyle (2004) NS Manager ability and support (R)
Capuano et al. (2005) Decreased Transformational leadership practices
through increased staff expertise (R)
Paquet et al. (2013) Decreased Unit manager support through reduced
absenteeism, overtime and nursepatient
ratio (R)
Vogus & Sutcliffe (2007b) Decreased Trust in leadership increased the effect of
safety organising behaviours (R)
Patient falls Houser (2003) Decreased Transformational leadership practices
through greater staff expertise and
stability (R)
Boyle (2004) NS Manager support ability and support
Capuano et al. (2005) Decreased Transformational leadership practices
through greater staff expertise (R)
Taylor et al. (2012) NS Positive perceptions of hospital
management (R)
Catheter use Castle and Decker (2011) Decreased Consensus leadership (R)
Pressure ulcers Boyle (2004) NS Inverse association with manager ability
and support (R)
Castle and Decker (2011) Decreased Consensus leadership (R)
Flynn et al. (2010) NS Inverse association with manager ability
and support (R)
Taylor et al. (2012) NS Positive perceptions of hospital
management (R)
Inadequate pain Castle and Decker (2011) Decreased Consensus leadership (R)
management
Hospital infections Houser (2003) Decreased Transformational leadership practices
(pneumonia and UTI) through greater staff expertise (R)
Boyle (2004) NS Nurse manager ability and support (R)
Capuano et al. (2005) Decreased Transformational leadership practices
through greater staff expertise (R)
Table 3
Continued
(b) Complications
Neonatal PIVH/PVL Pollack & Koch (2003) Decreased Higher leadership (combined ratings of
RNs, MDs & RTs) (R) & (T)
Retinopathy of prematurity(ROP) Pollack & Koch (2003) Decreased Only MDs composite leadership scores
(R) & (T)
Pulmonary embolism/ Taylor et al. (2012) NS Positive perceptions of hospital
deep vein thrombosis management (R)
Patient healthcare utilisation
Number of Gardner et al. (2007) NS Manager ability and support (R)
hospitalizations for
dialysis patients
Hospital readmission Hansen et al. (2011) NS Manager support (R)
rates (AMI, HF or
pneumonia)
Length of hospital stay Paquet et al. (2013) Decreased Manager support through reduced
absenteeism, overtime and nursepatient
ratio (R)
(35%) failed to include explicit theoretical or concep- Smith 1999, Houser 2003, Capuano et al. 2005). Gol-
tual frameworks to guide the research and seven eman et al.s (2002) resonant leadership (Cummings
(35%) failed to achieve or report acceptable et al. 2010b), the Bonoma-Slevin leadership model
(a > 0.70) alpha reliabilities of the measures used in (Castle & Decker 2011) and Bass and Stogdills
their studies. (1990) conceptualisation of task vs.-relations-oriented
leadership (Havig et al. 2011) were each used in one
of three studies. Thirteen different tools were used to
Leadership
measure leadership and the most frequently used tools
Leadership was measured in these studies as leadership were Bass and Avolios (1995, 2000) Multifactor
styles, behaviours, competencies and practices. The lead- Leadership Questionnaire (MLQ) (n = 3 studies), and
ership concepts or themes across studies were transfor- Kouzes and Posners (1995) Leadership Practices
mational/transactional leadership (McNeese-Smith Inventory (LPI) (n = 3 studies). In two studies mea-
1999, Houser 2003, Doran et al. 2004, Larrabee et al. sures of leadership were developed for the study: one
2004, Capuano et al. 2005, Raup 2008), relational, par- used items of other standardised measures to assess
ticipative or consensus leadership practices (Anderson task-and relationship-oriented leadership (Havig et al.
et al. 2003, Kroposki & Alexander 2006, Castle & 2011) and the other developed items to measure trust
Decker 2011), task- or relationship-oriented leadership in leadership (Vogus & Sutcliffe 2007b).
(Havig et al. 2011), resonant leadership (Cummings Leadership was measured using a component or
et al. 2010b), leader ability and support (Pollack & subscale of multi-dimensional measures of the work
Koch 2003, Boyle 2004, Gardner et al. 2007, Touran- context in seven studies. In fact this trend was evident
geau et al. 2007, Flynn et al. 2010, Hansen et al. 2011, in six of the 13 retained studies in the more recent
Paquet et al. 2013), trust in leadership (Vogus & Sutc- search. The most commonly used (n = 4 studies) mea-
liffe 2007b) and positive perceptions of leaders (Taylor sure was the manager ability and support subscale of
et al. 2012). Aiken and Patricians (2000) Nursing Work Index-
In nine studies (45%), an explicit leadership theory Revised (NWI-R) (Boyle 2004, Gardner et al. 2007,
was used as the basis for the leadership variable. Bass Tourangeau et al. 2007, Flynn et al. 2010) while in
and Avolios (1994) transformational leadership four studies manager support subscales of Singer
theory was used in three studies (Doran et al. 2004, et al.s (2009) Patient Safety Climate in Healthcare
Larrabee et al. 2004, Raup 2008) and Kouzes and Organizations (PSCHO) survey (Hansen et al. 2011),
Posners (1995) transformational leadership practices Sexton et al.s (2000) Safety Attitudes Questionnaire
model was used in another three studies (McNeese- (SAQ) (Taylor et al. 2012), Karasek et al.s (1998)
Figure 3
Structure-ProcessOutcome relation-
ships suggested by review findings.
styles (consensus and participative) and lower restraint and patient outcomes by extending the search criteria of
use in nursing homes. In two of three studies examin- the previous review to include studies published
ing hospital-acquired infections (pneumonia and uri- between 1985 and 30 July 2012. The 13 additional
nary tract infections) transformational leadership was studies published after our first systematic review
associated with lower infection rates (Houser 2003, almost triples the number of studies specifically examin-
Capuano et al. 2005). ing the relationship between nursing leadership and a
variety of patient outcomes. The totality of the 20
Patient safety outcomes: complications included studies reflects positive trends in terms of
Three types of complication outcomes were research design and methods. Most studies were multi-
addressed in two studies and thus there were few sited, incorporated multiple levels of analysis, used
studies for each type of complication limiting the more advanced statistical procedures (e.g. HLM, SEM)
ability to draw conclusions. Pollack and Kochs and examined the relationship leadership and patient
(2003) study conducted in neonatal intensive care outcomes in a wider variety of clinical settings, although
settings found a reduced incidence of neonatal peri- the majority were conducted in acute care. What was
ventricular haemorrhage/periventricular leukomalacia disappointing was that less than half of the studies used
(PIVH/PVL) associated with higher leadership rat- explicit leadership models, very few studies examined
ings. Taylor et al. (2012) found no relationship mechanisms of leadership influence on outcomes, there
between leadership and pulmonary embolism/deep was an over-reliance on cross-sectional designs and con-
vein thrombosis. siderable heterogeneity of patient outcomes and clinical
settings precluding greater synthesis of findings.
Patient healthcare utilisation The findings provide support for the assertion that
A new category of patient outcomes was added since relational leadership practices are positively associated
three studies addressed patient healthcare utilisation with some categories of patient outcomes. The Donabe-
indicators, specifically the number of hospitalisations, dian (1966) SPO model provided a useful approach to
hospital readmissions and hospital length of stay as out- organising findings which are summarised in a diagram
comes related to work environment factors including depicting suggested linkages between relational or task
leadership (Gardner et al. 2007, Hansen et al. 2011, oriented leadership, processes of leadership and three of
Paquet et al. 2013). Healthcare utilisation measures the patient outcomes where findings were supported in
reflect services or resources consumed in managing terms of number of studies and direction of effect (Fig-
patients health-related needs (Clarke 2011). Gardner ure 3). The findings highlighted a key relationship
et al. (2007) proposed that patient hospitalisations are between relational leadership and the reduction of
considered important indicators of the general health adverse events, specifically, medication errors, possibly
status of patients who are on dialysis and may be con- through leaders influence on human resource variables
sidered a reasonable nurse-sensitive quality indicator in that may be connected to patient care outcomes, staff
dialysis settings. Hansen et al. (2011) claimed that the expertise, turnover, absenteeism, overtime and nurse to
frequency of hospital readmission rates reflected an patient ratios. There were also promising trends in find-
inadequate patient safety process which means that ings for restraint use and hospital-acquired infections.
hospitals with poorer safety cultures would be expected Findings on mortality outcomes were strong showing a
to exhibit higher levels of hospital readmissions. Man- significant negative relationship between leadership and
ager support was included as one element of patient patient mortality in three of six studies. This important
safety culture. Both studies did not demonstrate signifi- connection may suggest that effective nursing leader-
cant findings for the effects of leadership on these two ship is essential to the creation of practice environ-
healthcare utilisation outcomes. However, Paquet et al. ments, with appropriate staffing levels, resources and
(2013) found that manager support was associated with care processes that support nurses in preventing unnec-
a lower patient length of stay through the human essary deaths (Wong & Cummings 2007). Finally, there
resource indicators of lower absenteeism, overtime and was a significant positive relationship between both
nurse to patient ratio. relational and task-oriented leadership and patient sat-
isfaction. This finding may indicate that some elements
Discussion of each style are needed to ensure care processes that
contribute to satisfied patients such as clear standards
In this systematic review we examined empirical evi- of care and role expectations as well as collaborative
dence on the connections between nursing leadership working relationships.
of leadership and the mechanisms of influence on patient Bass B.M. & Avolio B. (1995) Multifactor Leadership Ques-
outcomes is warranted to advance knowledge of the tionnaire (MLQ): Sampler Set Manual. Mind Garden,
Redwood City, CA.
complex contextual and multivariate influences on the
Bass B. & Avolio B. (2000) Multifactor Leadership Question-
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Bass B.M. & Stogdill R.M. (1990) Bass and Stogdills Hand-
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(2011) Nurse staffing effects on patient outcomes: safety-net
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Supporting information
Leadership Quarterly 14 (1), 2540.
Young-Ritchie C., Laschinger H.K.S. & Wong C. (2009) The Additional Supporting Information may be found in
effects of emotionally intelligent leadership behaviour on
the online version of this article:
emergency staff nurses workplace empowerment and organi-
zational commitment. Nursing Leadership 22 (1), 7085. Appendix S1. Characteristics of included studies.