Although studies showed increasingly rigorous
research designs and methods over the past decade,
cross-sectional or correlational designs were predominant
and considerable variety in patient outcomes and
clinical settings hampered greater synthesis of findings.
The trend toward more research to test links between
leadership and patient outcomes in a broader array of
settings such as ambulatory, home care and nursing
homes as well as acute care needs to be continued.
Research findings were still primarily associations and
not confirmed causal connections. Unraveling the
complex causal relationships between leadership and
patient outcomes, will require intervention and longitudinal
studies with repeated observations. While challenging
for researchers to carry out due to the level of
control necessary, studies of theory-based interventions
that change leadership practices and examine the
effects on individual, team, unit and organizational
outcomes would provide more convincing evidence for
and understanding of causal relationships (Gilmartin
& D’Aunno 2007).
Two other areas of concern were that less than half
of the studies tested leadership theories and very few
examined processes of leadership influence on outcomes.
While it is noteworthy that leadership is now
acknowledged as an important antecedent to patient
outcomes, the development and testing of robust conceptualizations
of leadership that clearly describe leadership
behaviours and identify the direct and indirect
mechanisms by which leaders affect individuals and
outcomes are urgently needed. Many of the studies
examined transformational leadership (Bass & Avolio
1994, Kouzes & Posner 1995). However, in a critical
analysis of transformational leadership research in
nursing, Hutchinson and Jackson (2013) recently
argued that flaws in conceptualizations and methods
in this body of research call for nurse researchers to
pursue “new ways of thinking about nursing leadership”
(p. 11) that adequately address the dynamics
and contextual drivers in modern day healthcare.
Also, we need to move beyond limited notions of leadership such as