Although the evidence base for the connection between leadership and patient outcomes is far from prescriptive, what we do know suggests that positive leadership is pivotal in creating working conditions that optimize nursing practice promoting high quality patient care. Professional work environments that foster strong nursing practice include collaborative teamwork, autonomous decision making, professional development, adequate staff and skill mix which are most closely aligned with patient safety outcomes. Although these environments are created by the contributions of both unit leaders and staff, leaders must have the vision, problem solving abilities and the relationship-building skills to navigate the dynamic contexts of organizations to obtain needed resources and support.