The impact of clinical nurse leadership models on the quality of care at the unit level: a systematic review

Abstract

Background

Effective leadership is one of the most critical factors in achieving successful outcomes for an organization. Therefore, modern healthcare needs effective clinical nurse leadership to improve the quality of care. This study aimed to analyse the effectiveness of clinical nurse leadership models and the impact that these models have on the quality of care at the unit level.

Methods

Initial searches were performed from January 2012 to January 2025 on the platforms PubMed, The Cochrane Library, Web of Science, EBSCO, Scopus and Science Direct. A total of 2822 articles were obtained, their abstracts and titles were read. The full texts of 84 articles were read and critically evaluated using the Mixed Methods Appraisal Tool. The screening of titles and abstracts, and subsequently full-text publications, was performed blinded by two author teams using the inclusion/exclusion criteria.

Results

A total of five studies satisfied the eligibility criteria and were included. Current evidence suggests associations between positive clinical nurse leadership, increased openness in communication, lower medical errors, higher quality of care and patient satisfaction and safety.

Conclusion

There is a positive association between clinical nurse leadership style and quality of care. However, future investigation of various clinical leadership models is required to test the best mechanisms to implement clinical leadership in nursing practice. Findings provide encouraging support for the conceptualization of clinical nurse leadership models at the unit level for nurse leaders. The organizational policies regarding the competencies of clinical nursing leaders needs to be improved to increase the quality of care at the unit level. Features of clinical nurse leadership models that have a positive impact on quality of care, should be taught in practice and academic environments.

Highlights

Why is this research needed?

What are the key findings?

The most effective CNL model is needed to improve the quality of care at the unit level in the health care system. There is no clear information on which CNL model is more effective on quality of care. There are a limited number of studies in the literature conducted on the impact of CNL models on the quality of care at the unit level.

When CNL models are implemented effectively, they have a positive impact on the quality of care at the unit level. There are effective CNL models that improve the quality of care at the unit level. Prospective studies with a high level of evidence are required to examine the CNL model that are the most effective in improving the quality of care at the unit level.

Introduction

Having effective leadership models for nurses has a significant impact on improving the quality of care and overcoming the problems they face in the healthcare system [1]. Hospitals need qualified nurses with leadership skills to positively change patient outcomes [2]. Therefore, modern health care services need effective Clinical Nurse Leadership (CNL) for quality of care. Given the growing pressures on healthcare systems, such as nurse burnout, staffing shortages, and increasing patient safety concerns, effective CNL is critical in fostering a positive work environment, ensuring high-quality care delivery, and addressing these systemic challenges [3–7]. Moreover, effective leadership is one of the most critical components that leads an organization to successful results [8]. Therefore, clinical nurses should be aware of the importance of developing leadership abilities and skills [2].

Clinical Nurse Leadership (CNL) represents a transformative initiative in the field of nursing. The CNL model was developed in response to the need for effective nursing leadership that can navigate the complexities of healthcare systems [9, 10]. CNL supervises and coordinates patient care, ensures quality improvement, and promotes a patient-centered care environment in a variety of healthcare settings. This leadership approach aims to improve patient care outcomes by integrating clinical leadership and management into daily nursing practice [9, 11]. Additionally, an ideal clinical nurse leader has several roles, including fostering support among colleagues, establishing professional relationships, deciding on staffing levels, and being involved in policy decision-making [12].

Quality of care and effective CNL are an essential elements for achieving high productivity levels within health care organizations [8]. CNL has been observed to improve outcomes through coordination and facilitation of high-quality health care [13]. CNL has a significant impact on quality measures, which is important when implementing new approaches to care [10]. However, as CNL courses are rather newly implemented, its impact on nursing leaders and on followers/co-workers are yet to be correctly determined. Similarly, the exact role and expectations of CNL tend to vary significantly according to the clinical unit, location, and other factors [3]. While CNL is believed to improve certain key areas of health care, it highly depends on the knowledge and skills of the individual, as well as their ability to coordinate and evaluate patient groups in complex health systems [2, 14]. CNL is also believed to aid at an organisational level by providing a competency skill-base and necessary leadership skills, allowing for the flourishment of interdisciplinary collaborations [5].

Many studies have made some attempt to identify the roles of nurse leaders in clinical settings in health care systems [3–5, 7, 14–18]. In Cook (2001) study collected evidence on the growth of CNL in the UK, USA and Australia from 1992 to 1997 [17]. This study critically reviewed CNL styles and evaluated how they can be used to affect change. Cook observed that leadership themes in clinical settings revolve around four main styles or combinations of them; Cook defined these styles as 1) transactional, 2) transformational, 3) connective, and 4) renaissance leadership styles. In addition, many studies have been conducted in the field of clinical nursing leadership and models such as emotional intelligence and laissez-faire have emerged [14, 16, 18].

Transactional leadership uses an exchange or transaction between workers, leaders and colleagues to accomplish work; this had been referred to as the autocratic leadership form in the past [19]. Transactional leadership is a task-oriented leadership style, and it is very effective when decisions need to be made with illness, such as during medical crises, however, it may have negative effects on patient outcomes [20]. Transformational leadership is an example of “rationally focussed leadership” which uses motivation as key to allow followers to believe they could exceed their own expectations [21]. Apart from motivation, transformational leaders also use individualised consideration and intellectual stimulation to achieve results; it is also related to democratic styles of leadership which involves leaders and employees engaged in a common objective of encouraging positive change and innovation [22, 23]. The connective leadership style aims to empower the workforce by building collaborative work and communication channels that support change; this theme has similarities to both transformational and renaissance themes [21]. Renaissance leadership requires the effective use of power and the ability to communicate on different levels to make stakeholders favour changes; this theme was previously called a ‘charismatic’ theme [17]. Emotional intelligence relates to the leaders’ capacity to express, perceive, understand and analyze their own and other individuals’ emotions. A nurse leader with emotional intelligence makes logical decisions and deeply understands the role and responsibility of leadership in a complex and dynamic health care services [16]. The laissez-faire leadership style involves a non-interventionist approach in which one cannot make decisions and acts without full direction or supervision of staff but results in rare changes [24]. Understanding how these styles apply in nursing settings can provide valuable insights into how CNL models can influence patient outcomes and staff satisfaction.

The different leadership behaviors of nurse leaders are becoming increasingly important in the health sector as they improve sustainability awareness, support institutional and personnel development [25]. Clinical nurse leaders’ knowledge of leadership types and their effective use of these leadership models increases the quality of care, staff and patient satisfaction [4, 7, 14–16, 26]. As a result, healthcare organizations need effective nursing leaders who understand the complexities within them and who have good relationships with their followers to achieve high effectiveness [27]. However, there is limited research in the literature on CNL models and how they may have a positive impact on quality of care at the unit level. Despite the growing recognition of the importance of CNL in enhancing care quality, there remains a significant gap in understanding how various CNL models specifically influence clinical outcomes and organizational effectiveness at the unit level. Identifying the most effective models is essential for guiding leadership development in nursing and ensuring that quality care is consistently delivered. The aim of this systematic review is to analyse the effectiveness of CNL models and the impact that these models have on the quality of care at the unit level. By identifying effective strategies, this review will contribute to the development of best practices for clinical nursing leadership in contemporary healthcare environments.

Methods

The present systematic review was designed and performed following the steps of the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) statement [28] to synthesize the existing literature about the impact of clinical nursing leadership style to improve quality of care at the unit level.

Search strategy and data sources

In this systematic review, the PICO model was used to describe all the components associated with the identified problem and to structure the research question. The acronym PICO stands for Population, Intervention, Comparison, and Outcome [29]. Specifically, the three components (PIO) that helped facilitate identification of relevant information in this study are as follows; (a) population- nurses and patients in clinical units; (b) intervention- use of different clinical nursing leadership styles; and (d) outcome- quality of care. Both nurses and patients are involved in this research problem because the changes in nurses’ knowledge and skills could also affect quality of care. The research question guiding this systematic review is: “What is the impact of different clinical nursing leadership styles on the quality of care at the unit level?’

To answer the research question, the list of initial search terms was agreed upon by the authors (SEA, HAD, EÜ). Then, to identify relevant search terms to add to the initial search term list, individual keywords search was done. We were thus assured that the search terms would cover all potentially relevant studies. The final search terms (clinical nursing, leadership style, quality of care) were used for the online search of the following six databases: PubMed, The Cochrane Library, Web of Science, EBSCO, Scopus, Science Direct. The initial search for eligible studies was conducted in October 2022 by two reviewers (SEA and HAD) to identify studies published between 2012 and October 2022. A subsequent search was performed to cover the period from October 2022 to January 2025. Articles were chosen by first reading the title and, if appropriate, the abstract before reading the full text. Eventual uncertainties about article inclusion were overcome through discussion among three reviewers (SEA, HAD, EÜ). In addition, screenings of previously published systematic reviews and meta-analyses were carried out to identify potentially relevant studies that could be included, ensuring a thorough overview of all published studies. We then checked the references of the selected publications to identify any additional relevant articles that were lost in the database search [8, 30, 31].

Inclusion and exclusion criteria

In this systematic review, articles were included if they met al.l of the following inclusion criteria: (1) studies written in the English language, (2) studies full-text published between January 2012 and January 2025, (3) studies published in peer-reviewed journal, (4) studies addressed one of the leadership styles, (5) studies included nurses working in the unit, (6), studies had designs relevant for the research question, (7) studies with clearly defined design and method.

Articles were excluded, if they were: (1) editorials, (2) reports, (3) protocols, (4) letters to the editor, (5) conference abstracts, (6), and if (7) studies’ population was student nurses, management nurses, doctors, and other healthcare staff. Studies that included multiple places (intensive care unit, acute care, aged people’s care centres) or other than inpatient ward were also excluded. This is because if studies included multiple places, and thus there was no possibility to separate the relationship between nursing leadership style and quality of care at the unit level alone.

Study selection

Two reviewers (SEA and HAD) independently assessed for eligibility of the studies based on pre-determined inclusion and exclusion criteria discussed by the three reviewers (SEA, HAD, EÜ). After elimination of duplicates, studies were chosen by titles and abstracts (SEA and HAD). Then full text of the studies was examined by three reviewers (SEA, HAD, EÜ). Uncertain situations were discussed among the team members to come to an agreement.

Data extraction and methodological quality assesment

Each retrieved study’s data was systematically extracted using a predesigned standard data collection form (extraction table). The following information were extracted from the included studies (Table 1): author, year, country, aim, study design, sample, setting, duration of the study, leadership style, instruments, main findings and suggestions. Data extraction of included studies were confirmed by three reviewers (SEA, HAD, EÜ).

Table 1.

Main characteristics of the studies included in the systematic review (n = 8)

Author, year and country	Aim	Study design	Sample	Setting	Duration	Leadership style	Instruments	Main Findings	Suggestions
Asif et al., 2019, Pakistan	This study was to examine the relationships between transformational leadership (TL), structural empowerment (SE), job satisfaction (JS), nurse-assessed adverse patient outcomes (APO), and the quality of care (QOC).	A cross-sectional data with a random sampling technique	386 nurse (response rate 64.33%)	17 government hospitals, which included 4 district headquarter hospitals and 13 tehsil headquarter hospitals situated in the Sargodha division, Punjab province, Pakistan,	from March to April 2019.	Transformational Leadership	*TL was evaluated using the 7 item scale developed by Carless, *12 items’ SE scale proposed by Laschinger *JS was evaluated using the 3 item scale proposed by Cammann *5 item scale to measure APO that was developed by Sochalski *A 4-item QOC scale developed by Aiken All 31 items used in this study were measured on a 5-point Likert’s scale.	The results of our study indicate that nursing leaders who exhibit transformational behavior significantly predict the desired patient’s outcomes by reducing the possibility of adverse patient outcomes (APOs) and increase quality of care (QOC).	Transformational leadership is a vital indicator that can help the healthcare organizations to improve quality of care, nurses’ job satisfaction, and reduce adverse patient outcomes. To overcome the occurrence of adverse events in healthcare organizations, it is recommended that top management should develop transformational leadership behaviours among nurse managers/leaders and provide such environments empowerment and autonomy in order to support their follower nurses.
Blizzard and Woods, 2020 The USA	The study examined relationships between nurses’ perceptions of implicit rationing of nursing care and leadership style in the nursing work environment.	Cross-sectional survey study	248 nurses	Direct-care nurses licensed in Oregon and working in acute-care hospitals	between September 11, 2017 to March 24, 2018.	Emotional Intelligent Leadership Competencies 13 items (Cummings et al., chose 13 items from the NWI-R that the researchers thought reflected EI leadership competencies of Goleman et al.)	-The Perceived Implicit Rationing of Nursing Care (PIRNCA) -The Revised Nursing Work Index (NWI-R)	Study findings support presence of EI leadership style and perceptions of a more positive nursing work environment are related to less perceived IRNC. Results showed a medium, significant effect of perceptions of EI leadership style on IRNC. Where NWI-R scores were lower, indicating perceptions of a more positive nursing work environment, less IRNC was perceived.	EI leadership style can be learned, and programs for nurse leaders to acquire and use these competencies may be valuable. Results of this study are evidence that the impact of an EI leadership style of nurse leaders on amounts of IRNC by direct-care nurses requires further exploration. Nurse executives, and nursing faculty in administrative-focused graduate programs, can provide development and education in EI leadership skills.
Cheng et al., 2016, Australia	The purpose of this paper is to examine the role of transformational leadership (TL) in developing social identity and its subsequent impact on team climate, intention to leave, burnout and quality of patient care among nurses.	Cross-sectional study	201 registered nurses	A large metropolitan public health service in Victoria, Australia	…	Transformational Leadership	-Multifactor leadership questionnaire (MLQ, Form 5X-short), -Social identity was measured with Hinkle et al. (1989) measure. -Team climate was assessed with the 38-item team climate inventory as adapted from Anderson and West (1998) -Oldenburg burnout inventory - Quality of care was measured by the modified version of the patient satisfaction scale as adapted from Bartram et al. (2012).	Results illustrate that social identification appears to be the psychological mechanism through which TL impacts important employee outcomes, including perceived quality of patient care. This study provides valuable insights into understanding the critical role of human resource management (HRM) practice and policy in healthcare environments.	Future research may consider conducting a longitudinal study on leadership, social identity and teamwork with a view to elucidate the casual direction of the relationship. Moreover, the implications of appointing a male leader in a female dominated industry also warrants further research attention.
den Breejen-de Hooge et al., 2021, Dutch	The aim of this study was to determine the association between quality of care and leadership styles and practices, and whether the characteristics of nurses influence this interaction.	Cross-sectional	655 nurses	Clinical wards in Dutch university medical centres	2018	Transformational leadership, transactional leadership, laissez-faire leadership.	-Multifactor Leadership Questionnaire (MLQ), version MLQ-6S -Nurse-reported quality of care (NRQC) questionnaire	Transformational leadership was significantly associated with quality of care which explained 5.9% of the total variance and the nurse characteristics gender, profession and type of practice area were significant influencing factors.	The findings indicate a pressing need for education and training for nurses in how to develop leadership and raising the awareness among strategic managers about the importance of leadership in health care is recommended.
Mendes and Fredique, 2014, Portekiz	To investigate to what extent nursing leadership, perceived by nurses, influences nursing quality.	Cross-sectional study	Our original sample included 283 employees; 184 questionnaires were received (65% response).	In a Portuguese health center.	Between August and October 2011	All nursing leadership models	*Considering the original scale’s dimensions, we decided to use a reduced version. Nursing leadership was therefore measured using 13 items *Nursing quality was measured through six items (Appendix), based on standards emerging from the Portuguese Nursing Association.	The theoretical model presents reasonably satisfactory fit indices (values above literature reference). Path analysis between latent constructs clearly suggests that nursing leadership has a direct and statistically significant effect on nursing quality.	Results reinforce several ideas propagated throughout the literature, which suggests the relationship’s relevance, but lacks empirical support, which this study corrects.

The methodological quality of the each included study was assessed by three reviewers (SEA, HAD, EÜ) utilizing the Mixed Methods Appraisal Tool (MMAT). The MMAT is a quality appraisal tool designed for literature that includes quantitative, qualitative, and mixed methods research articles [32]. Our inclusion criteria allowed for a range of study designs, so we used the MMAT to assess the quality of all the articles. Studies were included in this systematic review if they met at least three out of the five MMAT criteria. Any discrepancies in the quality assessment process were resolved through discussion among the reviewers to ensure methodological transparency and reproducibility. Regardless of the methodological quality rating, all studies that met the inclusion criteria were included in this systematic review. A summary of the quality assessment can be found in Table 2.

Table 2.

Results of critical appraisal for cross-sectional-correlational studies

Study details	Screening questions		Quantitative non-randomized
	Are there clear research questions?	Do the collected data allow to address the research questions?	Is the sampling strategy relevant to address the research question?	Is the sample representative of the target population?	Are the measurements appropriate?	Is the risk of nonresponse bias low?	Is the statistical analysis appropriate to answer the research question?
Asif et al., 2019, Pakistan	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Blizzard and Woods, 2020 The USA	Yes	Yes	Yes	Yes	Yes	Partial	Partial
Cheng et al., 2016, Australia	Yes	Partial	Partial	Yes	Yes	Partial	Yes
den Breejen-de Hooge et al., 2021, Dutch	Yes	Yes	Yes	Yes	Yes	Partial	Yes
Mendes and Fredique, 2014, Portekiz	Yes	Partial	Partial	Yes	Yes	Yes	Yes

Results

Search results

The PRISMA protocol was used to guide the selection of the five studies that resulted from the scans (Fig. 1). A total of 2822 articles were identified: PubMed (n = 112), The Cochrane Library (n = 7), Web of Science (n = 58), EBSCO (n = 34), Scopus (n = 1235) and Science Direct (n = 1366). 12 additional articles were found from references of identified articles and from published systematic reviews and meta-analyses. The full texts of 84 articles were read and critically evaluated using the MMAT critical assessment checklists. Five studies were included in this systematic review after considering the inclusion and exclusion criteria [4, 7, 14–16].

Fig. 1.

PRISMA Flow diagram for search and selection of the included studies

Characteristics of studies

One of the selected studies was conducted in United States of America [16] and the remaining four were carried out in Netherlands [14], Portugal [7], Pakistan [15]), and Australia [4]. Studies were published between 2014 and 2021. All of studies in review utilized cross-sectional design. Table 1 lists the details of the main characteristics of the chosen studies.

Risk of bias within studies

The evidence from the five cross-sectional design was graded at Table 2 via the Mixed Methods Appraisal Tool (MMAT) Version 2018 User Guide [32]. All five studies had clear research questions [4, 7, 14–16] (Table 2).

In three studies, the sampling strategy was relevant to addressing the research question [14–16], but in two studies, it was not [4, 7]. In all included studies, the sample was representative of the target population, and the measurements were appropriate. Nonresponse bias was low in two of the included studies [7, 15] and partial in three studies [4, 14, 16]. In four of the included studies [4, 7, 14, 15] statistical analysis was appropriate to answer the research question, but in one [16], it was not (Table 2).

Characteristics of participants

The five reviewed studies included a total of 1773 participants. Sample sizes of the included studies varied between a minimum of 201 and a maximum of 655 participants [4, 14]. All studies included nurses working in hospitals in areas of 17 government hospitals [15], acute-care hospital [16], a large metropolitan public health service [4], clinical wards in a university medical centre [14], and a health center [7]. Four used a mixed sample with most female participants [4, 7, 14, 16], while one only consisted of female participants [15]. Five studies provided information about the mean age of the nurses. In these studies, mean age of the nurses ranged between 39 and 40,5 years [7, 14]. In the other three studies, average age of 69.17% ranged between 21 and 30 years [15], 55% were between 30 and 50 years [16] and 53% were between 43 years and above [4]. In three studies [14–16], more than half of the nurses had a bachelor’s degree or higher education, in two other studies [4, 7] no information was found about the educational levels of nurses. In the two included studies [7, 14], nurses’ professional experience ranged from 16 to 17.1 years on mean. One study stated that 62.44% of nurses had 1–5 years of experience [15], and another study stated that they should only have at least six months of experience in the medical-surgical unit [16]. In one study, no information was found regarding nursing experience [4]. Only one of the included studies provided information about the clinic where nurses worked. In one of these studies, it was stated that all nurses worked in the medical-surgical unit [16]. In the remaining four studies, no information was given about the clinics where nurses worked [4, 7, 14, 15].

Characteristics of leadership styles

It was determined that different leadership models were discussed in the included studies. In two of these studies, the transformational leadership model [4, 15], and in one, the emotionally intelligent leadership model [16] was included. In one of the studies, three leadership models as transformational, transactional, and laissez-faire leadership were discussed [14]. However, in one study, a specific leadership model was not specified, while emphasizing a general leadership concept and model [7].

Outcome measures

In these studies, various measurement instruments were used due to different study purposes and leadership models (Table 1). In five studies, quality of care was evaluated with scales. Outcome measures of included studies were quality of care, nursing leadership style, transformational leadership, burnout, team climate, social identity, job satisfaction, nursing work environment, structural empowerment, and nurse-assessed adverse patient outcomes. In total, 16 different measuring instruments were used to measure outcomes. The instruments used were all different from each other. Only two studies [4, 14] used different versions of the Multifactor Leadership Questionnaire (MLQ) (MLQ-6S and MLQ Form 5X short). Five instruments were used in the two included studies [4, 15], and two instruments were used in others three studies [7, 14, 16]. In addition, all of studies used different surveys or scales to measure quality of care. The reliability and validity of the utilized scales were outlined in all studies [4, 7, 14–16]. Outcome measures of included studies were given in Table 1.

The impact of nursing leadership style to improve quality of care

In all included studies, CNL types were found to have a positive impact on quality of care. In two of the studies, it was found that the transformational leadership type helped provide good patient care and improves the quality of care [4, 15]. In one of the studies, the transformational leadership model, one of the CNL models, was compared with other CNL models, and it was found that the transformational leadership model was more effective on the quality of care than the transactional leadership and laissez-faire leadership models [14]. In one of the studies, it was stated that an emotionally intelligence leadership style positively affected the quality of care [16]. In one of the studies, it was emphasized that CNL types were not used much in health care; however, they could have a positive impact on the quality of patient care if implemented well [7]. The connections between leadership types and quality of care are presented in Table 3.

Table 3.

The impact of leadership models on quality of care

Lidership Style	Impact on quality of care
Transformational Leadership	Asif et al. (2019) found that nursing leaders’ transformational behaviors significantly predicted desired patient outcomes and increased the level of quality care by reducing the likelihood of adverse patient outcomes. This finding shows that nursing leadership plays a critical role in improving the quality of care and ensuring patient safety in healthcare. Cheng et al. (2016) show that transformational leadership (TL) has a positive effect on team climate and patient care quality among nurses, and also reduces nurses’ intention to leave the institution they work for and their burnout. Mendes and Fredique, 2014, emphasized that all nursing leadership models can have a positive impact on the quality of care when implemented correctly and effectively.
Transactional Leadership	den Breejen-de Hooge et al. (2021) compared transformational leadership, transactional leadership and laissez-faire leadership models with each other and found that the transactional leadership model was less effective on the quality of care than the transformational leadership model. Mendes and Fredique, 2014, emphasized that all nursing leadership models can have a positive impact on the quality of care when implemented correctly and effectively.
Laissez-faire Leadership	den Breejen-de Hooge et al., (2021) found that the Laissez-faire Leadership model was less effective on quality of care than transformational leadership and transactional leadership models. Mendes and Fredique, 2014, emphasized that all nursing leadership models can have a positive impact on the quality of care when implemented correctly and effectively.
Emotionally Intelligent Leadership	Blizzard and Woods (2020) show that there is a positive relationship between nurses’ EI leadership style and the quality of nursing care. The poor analytical intelligence and organizational skills of the leaders in the nurses’ work environment and their lack of consideration for others’ feelings negatively affect the discharge time of the patients. Mendes and Fredique, 2014, emphasized that all nursing leadership models can have a positive impact on the quality of care when implemented correctly and effectively.

Discussion

This study outlined the current available evidence regarding the impact of CNL styles on improving the quality of care at the unit level. Five papers matched the requirements for inclusion, and they were all reviewed. Overall, the results suggest that CNL styles may positively impact quality of care at the unit level. CNL styles were found to have positive effects in all studies [4, 7, 14–16].

A total of eight systematic review studies were found in this review. Five of these were obtained through examining databases, and three were obtained through examining the references of five research articles included in this systematic review. In line with the findings from these systematic reviews [6, 8, 10, 23, 30, 31, 33, 34], the findings of this review produced evidence that CNL models are effective in improving quality of care. However, unlike other systematic reviews, this review is more specific since it only investigates the most effective CNL models at the unit level.

Alilyyani et al. (2018) included 21 quantitative studies published between 2004 and 2017 that addressed authentic leadership, which is one of the other nursing leadership models rather than CNL models. In addition, Alilyyani et al. (2018) grouped the results of the authentic leadership model in health care under two main themes: health care personnel and patients [33]. Similarly, Cummings et al. (2021) examined all nursing leadership models and tried to determine the effectiveness of interventions to improve these leadership models [6]. However, this study analyzed 93 quantitative studies (44 correlational-49 interventional studies) published between 2007 and 2020. It examined a total of 105 factors in the included correlational studies and concluded that some of these studies were positively correlated with leadership, while others were not significantly correlated. In addition, it was found that the included leadership intervention studies had a positive impact on the development of leadership models, with the most common being the relational leadership model. In addition, three systematic reviews focused on various leadership models and examined the correlation between these leadership models and nursing workforce, organizational outcomes, nurse burnout and patient outcomes [10, 23, 34]. Although other systematic reviews focused on nursing leadership models and quality of care [8, 30, 31], the impact of CNL models on improving quality of care at the unit level was not addressed. Nurse leaders may exhibit different leadership behaviours in different departments and roles within health care systems, which may alter the results of systematic reviews [31]. Although the CNL models have shown promise, their implementation in real-world healthcare settings is not without challenges. Resistance to change among staff members and limited resources for leadership development can hinder the successful adoption of CNL models. To overcome these barriers, healthcare institutions should ensure that leadership development programs are in place and that the benefits of these models are clearly communicated to all staff members. Furthermore, a phased implementation approach could help ease the transition and foster acceptance across healthcare teams. In this context, our systematic review is the first systematic review to focus on the studies conducted on the most effective CNL models at the unit level published between 2012 and 2025, rather than examining the most effective nursing leadership model in all parts of health care systems.

Although the quality of most of the five studies included in this review was moderate, the studies had some methodological limitations. First, the sample sizes were different, with four studies having most female participants [4, 7, 14, 16] and one having only female participants [15], which may have an impact on the generalizability and representativeness of the sample. Therefore, further research is required to determine whether nursing leadership style influence the quality of care improvement at the unit level with a more balanced sample of male and female nurses [4, 15]. Second, three of the studies included in this systematic review did not provide information about the mean age [4, 15, 16] and the other two did not provide information about the educational level [4, 7] of the participants. The effectiveness of CNL model at the unit level may differ according to age and educational level. In this context, education of nurses in this field can improve their personal leadership and increase the quality of patient care. Another methodological limitation is that in four studies [7, 14–16], the duration of professional experience of nurses ranged from six months to 21 years, while one study did not provide such information [4]. In the literature, it is reported that age and leadership experience affect nursing practices [6, 35]. In addition, in four of the studies included [4, 7, 14, 15], the clinical area where the nurses worked was not specified. It is considered that the effect of unit-level clinical leadership models on quality of care may vary according to nursing experience and clinical unit.

Future research should aim for more robust methodologies, including larger and more diverse sample sizes that reflect the gender, age, and experience diversity seen in healthcare settings. A balanced representation of male and female nurses is essential to enhance the generalizability of the findings. Additionally, future studies should prioritize the inclusion of comprehensive demographic data, such as educational background and clinical experience, to better assess how these factors interact with leadership styles in influencing care quality. In addition, four of the included studies were conducted in developed countries [4, 7, 14, 16], while only one was conducted in a developing country [15]. Therefore, it should be examined whether such new studies can be applied in low-income countries and the results should be shared with researchers. It is essential to conduct future studies across a variety of healthcare settings, including rural and urban hospitals, to understand the applicability of CNL models in different organizational contexts. Cross-cultural research will also help determine whether CNL leadership styles are universally effective or if modifications are needed based on cultural differences in healthcare delivery.

The reviewed studies examined the transformational leadership model [4, 15], the emotional intelligent leadership model [16], the transformational, transactional, and laissez-faire leadership together [14], one study mentioned the general leadership concept [7]. Although the main point of this review was to reveal which of the CNL models had the most effect on the quality of care, the fact that one of the studies did not include any relevant information may have limited the generalizability of the finding. The organizational context in which CNL models are applied plays a crucial role in their effectiveness. Leadership development is a dynamic process and health care organizations should strengthen and develop existing leadership to ensure the future sustainability of the nursing workforce [19, 36]. In institutions with a strong culture of teamwork and continuous improvement, the integration of CNL models is likely to lead to better patient outcomes. Conversely, healthcare organizations that lack such a culture may struggle to implement these leadership models effectively. Therefore, healthcare leaders should prioritize fostering a supportive work environment that aligns with the principles of CNL leadership to maximize its benefits.

The included studies varied not only in terms of outcome measures but also in terms of measurement instruments. In the studies, quality of care was assessed with 16 different measurement instruments and there were some issues in reporting. However, it should be noted that there is not much diversity in the measurement instruments used in this regard [37]. In addition, five studies [4, 7, 14–16] mentioned the validity and reliability of the scales used, which is an important indicator of the quality of the measurement instrument [37]. Since leadership and quality of care are complex concepts, they are both measurable and unmeasurable concepts that are difficult to fully explain in a single instrument [38]. Therefore, further research is needed to investigate the relationship between the CNL model of nursing leadership, quality of care in various health care settings and the effectiveness of the measurement instrument used in these studies affect quality of care more. Given the complexity of both leadership and quality of care, future studies should adopt multi-dimensional measures that assess a range of outcomes, including patient safety, nurse job satisfaction, and team climate. Standardizing measurement tools would allow for more accurate comparisons across studies. In addition, developing new and high-quality measurement tools related to leadership models and investigating the effects of these leadership models on the quality of care in developing countries will make positive contributions to the literature. Additionally, a comprehensive, mixed-methods approach that combines both quantitative and qualitative data will provide a deeper understanding of the impact of CNL models.

High-quality studies using validated and widely used measurement instrument should be conducted to determine which CNL models have a greater impact on quality of care. Two of the included studies [4, 15] reported that transformational leadership style and the other one [16] reported that emotional intelligence leadership style improved quality of care. In one of the included studies [14], transformational leadership model was more effective on quality of care compared to transactional and laissez-faire leadership models. However, in one of the studies [7], it was emphasized that CNL models were not used much in health care; however, they could improve the quality of patient care when implemented well. While the studies in this review suggest a positive impact of CNL models on quality of care, a more nuanced understanding is required to determine which specific CNL models are most effective. The literature emphasizes that effective CNL models improve health care quality and patient outcomes [10, 19, 23]. The differences in the results may be associated with the functioning of health care institutions, differences in the population and the units. These differences underline the importance of considering context when selecting an appropriate CNL model. In addition, while the effect of clinical leadership models on quality of care was investigated in the studies, only a few leadership models were compared with each other and no study was found in which all of them were compared together. Future studies should focus on the development of strong leadership models not only at the unit level but also in various health care settings. These studies should include individual, institutional and organizational expectations with a multidisciplinary team and conduct a multidimensional measure for quality of care.

Strengths and limitations

The four-step search strategy attempted to select all possible papers in relevant six databases.

The included studies were limited to those written in English only, which is thought to cause language bias, but in our study, we used databases that are valid all over the world. These databases mostly cover English studies. Accessing articles published in other languages requires consulting different databases, which may narrow the scope of the study. If the population of the studies consisted of student nurses, nurse managers, physicians, and other healthcare personnel, they were excluded. In addition, due to the specificity of the research question, only nurses working at the unit level were included, which required the exclusion of units such as intensive care units, acute care units, and elderly care centers. Although this made our study more specific, it limited the number of research articles that met the inclusion criteria.

The methodological quality of the included studies varied, with some studies demonstrating moderate or low rigor. This could affect the overall reliability and validity of the conclusions drawn from the findings. A lack of randomization and the use of non-experimental designs may limit the ability to draw causal inferences about the impact of CNL models on quality of care. Sample sizes in the included studies were also relatively small and consisted mostly of female nurses. In addition, all the studies included in the review utilized cross-sectional designs, this limitation means that the long-term effects of CNL models on quality of care are not well understood, and the sustainability of leadership impacts over time remains uncertain. The studies included in the review were conducted in a limited number of countries, which may not be representative of healthcare systems globally. Cultural, organizational, and regional differences in healthcare delivery could affect the applicability of the findings to different contexts, limiting the generalizability of the results to other countries or settings. In addition, the use of 16 different measurement tools for the five included studies and the lack of a specific measurement tool for each leadership model did not allow a clear conclusion to be reached as to which of these leadership models was most effective on the quality of care. Lastly, limited studies assessed CNL models on the quality of care at the unit level, which made it difficult to confirm the most effective models.

Implications for nursing leadership

The findings of this systematic review have several practice, policy and educational implications. From a practical perspective, the review results reveal that nurse leaders’ use of CNL models can be effective in improving the quality of care at the unit level. Nurse leaders can develop skills that are consistent with the basic qualities of CNL models, comprehensively address the expectations of the institution, and embrace a multidisciplinary team approach. The findings suggest that organizations need to encourage for the conceptualization of CNL models at the unit level for nurse leaders. On the other hand, nurse leaders should support clinical nurses who are involved in all areas of care to provide more professional care to patients.

Additionally, the review suggests that organizational policies regarding the competencies of clinical nursing leaders need to be improved to increase the quality of care. Leadership models such as transformational and emotional intelligence, which have a positive impact on the quality of care, should be taught in practice and academic environments, particularly at the unit level. A policy agenda is also necessary to institutionalize clinical leadership as the core value system in health care institutions. Future research should consider testing the effects of CNL models on the quality of care at the unit level to determine the most effective CNL models on the quality of care at the clinical level.

Conclusions

Nursing leadership models are important in improving the quality of patient care at the unit level. Among all the compiled studies, the most frequently mentioned and used CNL model in the nursing literature was the transformational leadership theory. The transformational leadership model is thought to be more effective on the quality of care than other nursing leadership models. However, it is recommended to focus more on studies examining the effects of emotional intelligence nursing leadership models on the quality of care and to compare this leadership model with the transformational leadership model. It is argued that effective transformational leadership leads to innovation; innovation can lead to change, and this change can improve health care, service delivery and quality standards. The first step for a health service implementing transformational leadership should be to identify its current leaders and review their skills and competencies. The second should be to help these leaders improve and appreciate their transformational leadership capacities. The third is to identify the obstacles to the implementation of transformational leadership and how these obstacles can be eliminated. In conclusion, further research is essential to explore the relationship between CNL leadership styles and quality of care. Future studies should focus on expanding sample size, standardizing measurement tools related to leadership models, and considering the specific healthcare settings where CNL models may have the greatest impact. Moreover, the development of leadership models that account for institutional, organizational, and cultural factors will ensure that the impact of CNL leadership on quality of care is maximized. By addressing these gaps, we can provide stronger evidence to guide healthcare organizations in adopting effective leadership models that improve patient outcomes across diverse healthcare systems.

Author contributions

SEA: conception, design, search strategy development, database searching, study selection, data extraction, collection, analysis and writing of the manuscript. HAD: database searching, independent review of articles during the study selection, data extraction process, analysis and writing of the manuscript. EÜ: study conception, design, study selection, quality assessment, data analysis and the overall critical review of the manuscript, quality appraisal. KS: study selection, quality assessment, and overall critical review of the manuscript.

Funding

This article will be supported by Turkish Scientific and Technological Research Institution (TUBITAK) with EQUAL program.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Human ethics and consent to participate

Not applicable.

Consent to publish

Not applicable.

Competing interests

The authors declare no competing interests