Head nurse leadership styles and job satisfaction among nurses in teaching hospitals of southeastern Iran: a cross-sectional study

Abstract

Background

The leadership style of head nurses is widely recognized as a critical factor influencing nurse job satisfaction, which in turn affects retention rates and the quality of patient care. However, the extent to which this relationship holds in settings with unique organizational challenges remains insufficiently explored. Therefore, this study aimed to examine the relationship between the leadership styles of head nurses and nurse job satisfaction in Iran.

Methods

This descriptive-analytical cross-sectional study was conducted in southeastern Iran from November 2024 to June 2025. A random sample of 381 nurses and a census of 30 head nurses were selected. Data were collected using the Leader Effectiveness and Adaptability Description (LEAD) questionnaire to assess leadership styles and the Warr-Cook-Wall scale to measure job satisfaction. Data analysis was performed using hierarchical regression.

Results

The most prevalent leadership style identified in the head nurses’ self-assessments was Supporting (S3: 31.17%), while the nursing staff most frequently perceived their leaders’ style as Coaching (S2: 27.45%). Nurses reported a relatively high mean job satisfaction score (58.54 ± 11.95). Importantly, hierarchical regression analysis revealed no statistically significant relationship between head nurses’ leadership styles and nurse job satisfaction (p > 0.05).

Conclusion

The findings show that a direct relationship between leadership style and nurses’ job satisfaction was not evident in this context, possibly due to the influence of strong organizational factors and the limited managerial experience of head nurses. These findings suggest that future research should focus on organizational conditions and the development of adaptive leadership skills.

Clinical trial number

Not applicable

Introduction

The nursing shortage is a significant global issue that places considerable strain on healthcare systems worldwide. According to the 2025 State of the World’s Nursing report by the World Health Organization, the number of nurses increased from 27.9 million in 2018 to 29.8 million in 2023. However, a critical shortage of approximately 5.8 million nurses persists, although it is projected to decline to 4.1 million by 2030 [1].

The current shortage of nursing professionals has resulted in a high workload for the remaining staff, significantly affecting their work-life balance and overall performance, and ultimately compromising the quality of care provided to patients [2]. Several factors contribute to this situation, including increased workloads, inadequate technological support [3], and deficiencies in essential skills and competencies, such as problem-solving abilities and nursing informatics [4]. Beyond immediate technical skills, organizational and interpersonal factors play a critical role in the development of nursing performance. For example, communication skills, self-confidence, organizational commitment, quality of work life, job-related stress, and intrinsic motivation are all closely linked to leadership and management practices [5–9]. Effective leadership creates positive work environments that enhance empowerment, autonomy, and professional growth, whereas poor leadership contributes to burnout and reduced resilience among nurses [10]. Therefore, developing effective nursing leaders has become a strategic necessity to create conducive working conditions and promote nurse well-being. Various nursing leadership styles exert both direct and indirect influences on the nursing profession, healthcare professionals, patient outcomes, and organizational performance. Within hospital settings, leadership is regarded as a fundamental component of effective and integrated care delivery [11].

The quality of care is one of the most commonly used metrics to evaluate nursing performance in modern healthcare settings. It is typically assessed through patient outcomes and the achievement of organizational objectives [12]. Effective leadership is recognized as a crucial factor in promoting responsible behavior among nurses [13]. Conversely, rude behavior from supervisors can negatively impact nursing performance [14]. Nursing leadership plays a significant role in influencing nursing performance, which is essential for meeting organizational goals related to delivering quality care and improving patient outcomes [15, 16]. The structural and psychological environments shaped by head nurses are key determinants of job satisfaction, team morale, efficiency, and staff retention [17–19]. Therefore, leadership that actively engages and empowers nurses is essential to ensure high-quality care and a healthy work environment [20].

Retaining staff, enhancing productivity, and ensuring efficiency are crucial for healthcare organizations. Therefore, head nurses should develop their skills by employing research-based methods [21]. However, questions remain regarding how different leadership approaches relate to variables such as job satisfaction, commitment, and performance among healthcare staff. Nurses’ job satisfaction is particularly important, as nurses constitute the largest professional group within healthcare systems [22]. Numerous studies emphasize that improving job satisfaction is essential for maintaining care quality and ensuring patient satisfaction [23]. Effective leadership will result in the creation of an organizational culture that promotes teamwork, minimizes conflict, and enhances efficiency, productivity, and employee satisfaction [24–26]. These effects, in turn, enhance staff motivation, engagement, and retention, leading to improved overall hospital performance [27]. According to Jean Watson, a prominent nursing theorist, one of the most significant factors influencing job satisfaction is the leadership style of the head nurses [28]. Although previous research has established a link between leadership and job satisfaction [20, 29, 30], further investigation is needed to clarify nurses’ perceptions of leadership styles and their impact across different contexts [26].

Although numerous studies have examined leadership styles and nurse job satisfaction, most have relied on cross-sectional designs and self-reporting, which complicates drawing causal conclusions and may introduce potential bias. Furthermore, a significant portion of the literature in this field originates from high-income countries, where organizational structures, hierarchical values, and leadership styles differ from those in developing contexts such as Iran [31]. Systematic reviews of nurse leadership in high-income countries consistently report positive associations between transformational, coaching, or supportive leadership styles and nurse job satisfaction [32, 33]. In contrast, studies from low- and middle-income countries (e.g., Iran, Brazil, South Africa) present more heterogeneous results, with many reporting weak or non-significant associations. These findings are often attributed to systemic constraints such as staffing shortages, limited managerial authority, and hierarchical organizational cultures [34–36]. Situational Leadership(SL) explicitly requires leaders to align their behavior with staff competence and commitment [37]. While transformational leadership is linked to improved nurse outcomes and positive work environments, it is often considered most effective in relatively stable organizational settings. In contrast, situational leadership provides greater flexibility, allowing leaders to adapt their style to nurses’ varying levels of competence and motivation—an approach that may be particularly valuable in resource-constrained hospital environments [33]. SL posits four styles—Directing, Coaching, Supporting, and Delegating—each suited to specific levels of staff readiness [37].

While the importance of leadership is well documented globally, few studies have examined how leadership styles impact nurse job satisfaction within the unique cultural, organizational, and resource-constrained contexts of Iranian hospitals. Systemic challenges in the Iranian healthcare environment—such as severe nurse shortages, excessive workloads, limited managerial autonomy, centralized decision-making, and inadequate physical infrastructure—are prevalent organizational issues. These factors limit head nurses’ ability to influence the work environment and staffing decisions [38, 39]. Recent research shows that transformational leadership enhances structural empowerment, which in turn increases nurses’ job satisfaction [40]. Organizational and professional autonomy—core elements of empowerment—are consistently linked to higher satisfaction [33]. Studies examining these pathways have found that empowerment mediates the relationship between leadership and job satisfaction [41, 42]. Iran’s hierarchical professional culture, strong respect for authority, and limited managerial autonomy constrain head nurses’ leadership and its influence on nurses’ job satisfaction; however, few studies have examined this relationship in Iranian hospitals [43, 44]. The purpose of this study was to determine whether head nurses’ leadership styles (Directing, Coaching, Supporting, Delegating) are associated with nurses’ job satisfaction. Prior research consistently reports a positive link between leadership behaviors—particularly transformational, coaching, and supportive styles—and nurse satisfaction, retention, and quality of care [45, 46]. Accordingly, we hypothesized that greater use of Coaching (S2) and Supporting (S3) styles would predict higher job satisfaction scores among staff nurses. This study aimed to examine the relationship between head nurses’ leadership styles (as per the Situational Leadership model) and job satisfaction among nurses in teaching hospitals in southeastern Iran. Based on the existing literature emphasizing the positive role of relational leadership, we tested the following hypotheses:

H1

A higher perceived use of Coaching (S2) and Supporting (S3) leadership styles by head nurses will be associated with higher job satisfaction among nurses.

H2

Leadership styles will explain a significant portion of the variance in nurse job satisfaction beyond the effects of demographic variables (age, education, work experience).To address this gap, the present study was conducted in 2025 and examined the impact of head nurses’ leadership styles on job satisfaction among nurses in teaching hospitals affiliated with Kerman University of Medical Sciences.

Methods

Design and participants

This descriptive-analytical cross-sectional study aimed to examine the relationship between the effectiveness of head nurses’ leadership styles and the job satisfaction of nurses employed at four teaching hospitals affiliated with Kerman University of Medical Sciences. These hospitals offer general medical and surgical services, as well as specialized units, and serve as major educational and referral centers in southeastern Iran. The study was conducted from November 2024 to June 2025.

Sample size and sampling

Cochran’s formula was used to select a sample of 381 nurses from a population of 1,290 nurses employed in hospitals affiliated with Kerman University of Medical Sciences. The parameters used in the calculation included a 95% confidence level, a 5% margin of error, and an estimated population proportion (p) of 0.5. Based on these parameters, the required sample size was calculated to be 384, which was slightly adjusted to 381 to account for accessibility and the expected response rate. Additionally, a post hoc power analysis (α = 0.05, f² = 0.02, seven predictors) conducted using G*Power software indicated a statistical power of approximately 0.82, confirming the adequacy of the sample size for the hierarchical regression model. A simple random sampling method was employed to select the nurse participants. The sampling procedure was as follows: First, a comprehensive sampling frame of all 1,290 eligible nurses was compiled. Each nurse on this list was assigned a unique identifier. Using a computer-based random number generator, 381 unique numbers were generated. The nurses corresponding to these randomly selected identifiers were then invited to participate. This process ensured that all eligible individuals had an equal probability of selection. Given that 30 head nurses were working in these facilities, all were selected using a census method. The researcher explained the study objectives and the questionnaire completion process during individual interviews with each participant. Those who agreed to participate were asked to read and sign a written consent form before involvement. Questionnaires were distributed and collected individually. Participants were reminded that their information would remain confidential. No interventions by the researcher occurred within the research environment. Inclusion criteria comprised nurses holding at least a bachelor’s degree with more than one year of nursing experience, and head nurses with a minimum of six months’ experience in the roles of head nurses, employed at the hospital during the research period. Exclusion criteria included nurses on extended leave (e.g., maternity, medical, or study leave), those on secondment or temporary assignment, non-permanent agency staff, non-clinical personnel, and those who returned incomplete questionnaires. Data collection was conducted through individual, face-to-face sessions. The researcher first met with each participant to explain the study objectives and questionnaire completion process, after which written informed consent was obtained. Questionnaires were distributed on-site and completed independently by participants. To prevent bias, head nurses and their staff completed the questionnaires separately and were instructed not to discuss their responses. The researcher collected the completed questionnaires directly; any incomplete questionnaires were excluded from analysis. This procedure ensured standardized administration, minimized missing data, and preserved response integrity. All participants were reminded of the confidentiality of their responses and assured that no interventions would occur in their work environment. Of the 381 returned questionnaires, 5% contained one or more missing items. Little’s MCAR test was non-significant (p > 0.05), indicating a random pattern of missingness. Missing values were imputed using mean substitution for each scale, consistent with the approach recommended for instruments.

Data collection instruments

The study employed a two-part questionnaire to collect data. The first part, which gathered demographic information, included questions about gender, age, marital status, education level, and work experience.

The second part utilized the Leader Effectiveness and Adaptability Description (LEAD) instrument, developed by Hersey and Blanchard at the Center for Leadership Studies. The instrument is available in two formats: self-assessment and other-assessment. The self-assessment questionnaire was completed by head nurses, while the other-assessment was completed by nursing staff. Each questionnaire presented 12 scenarios, each with four response options. All responses corresponded to one of the leadership styles outlined in Hersey and Blanchard’s Situational Leadership Theory, which classifies leadership into four styles: S1—Telling/Directing (high task orientation, low relationship orientation), S2—Selling/Coaching (high task and relationship orientation), S3—Participating/Supporting (low task orientation, high relationship orientation), and S4—Delegating (low task and relationship orientation). After reviewing each scenario, both the head nurses and nursing staff selected the behavior that most accurately reflected the head nurse’s approach in that situation. Validity scores for adaptability, based on the 12-item assessment, ranged from 0.11 to 0.52, with 10 of the 12 coefficients (83%) being 0.25 or higher. Eleven coefficients were significant at the 0.01 level, and one was significant at the 0.05 level. The reliability of the LEAD self-assessment was moderately strong. In two administrations conducted over a six-week interval, 75% of managers maintained their dominant style, and 71% retained their alternative style. The contingency coefficients for both styles were 0.71, each significant at the 0.01 level [47]. Bruno et al. (2008) reported a Cronbach’s alpha of 0.75 and a validity coefficient of 0.83 [48]. This questionnaire has previously been used within the Iranian community, demonstrating reliability coefficients of 0.94 for self-assessment and 0.95 for staff evaluation [49]. The analysis of leadership styles from the LEAD questionnaire was conducted at the group level to describe the overall distribution of leadership behaviors. For each group (head nurses in self-assessment and nurses in other-assessment), the total number of times each leadership style (S1–S4) was selected across all 12 scenarios was summed. The percentage prevalence for each style, as reported in Table 2, was calculated as follows: (total number of selections for a specific style ÷ total number of leadership responses for the group) × 100. The total number of leadership responses was determined by multiplying the number of participants by 12 (the number of scenarios). This approach provides an aggregate view of the frequency of all leadership behaviors exhibited within the sample, rather than categorizing each individual into a single dominant style.

Table 2.

Distribution of leadership styles reported by head nurses and perceived by nurses

Leadership Styles	Self-Assessment (Head Nurses) (n = 30)	Nurse Assessment (n = 381)
	n (%)	n (%)
Directive (S1)	7(22.7)	82(21.57)
Coaching (S2)	8(25)	105(27.45)
Supporting (S3)	9(31.17)	100(26.33)
Delegative (S4)	6(21.12)	94(24.51)

Note1: The most common leadership style reported by head nurses was Supporting (S3, 31.17%), while they most frequently perceived their leaders as using the Coaching style (27.45%)

Note2: Percentages represent the proportion of total style selections for each group, calculated as (number of selections for a specific style ÷ total number of leadership responses) × 100. The total number of responses equals the number of participants multiplied by the 12 questionnaire scenarios

The third section utilized the Warr-Cook-Wall Job Satisfaction Scale, a 15-item instrument rated on a five-point Likert scale ranging from 1 (Extremely dissatisfied) to 5 (Extremely satisfied). The total score is the sum of all responses, yielding a range from 15 to 75, with higher scores indicating greater job satisfaction. The original scale demonstrated high reliability, with a coefficient alpha ranging from 0.85 to 0.88, and the correlation coefficient was over a six-month period [50]. The questionnaire was adapted and translated into Persian. Cronbach’s alpha for the 15-item scale was 0.88 (n = 397), indicating high reliability. Additionally, the polyserial correlations between the individual items of the scale and the total score ranged from 0.53 to 0.76 [51].

Data analysis

Data were analyzed using SPSS software (version 26). Descriptive statistics—including frequencies, percentages, means, and standard deviations—were used to summarize participants’ demographic characteristics, the distribution of leadership styles among head nurses, and nurses’ job satisfaction scores. A hierarchical multiple regression analysis was conducted to evaluate the extent to which head nurses’ leadership styles predict nurses’ job satisfaction, controlling for age, education level, and work experience. In the first step of the regression, the control variables (age, education level, and work experience) were entered. In the second step, the four leadership styles (Directing, Coaching, Supporting, and Delegating) were added to the model. The significance level was set at α = 0.05. For the hierarchical multiple regression analyses, all standard regression assumptions were assessed at each block entry. Linearity, homoscedasticity, and normality of residuals were evaluated using residual plots and normal probability plots. Independence of errors was assessed with the Durbin–Watson statistic. Multicollinearity was examined using variance inflation factors (VIF) and tolerance values. Outliers and influential observations were identified through standardized residuals, leverage statistics, and Cook’s distance. All assumptions were met, and no influential cases were detected (Cook’s distance < 1 across all models).

Results

A total of 381 nurses and 30 head nurses from hospitals affiliated with Kerman University of Medical Sciences participated in the study. The majority of nurses were female (79.6%), married (78.2%), and held a bachelor’s degree (89.8%). The mean age of the nurses was 35.4 ± 7.65 years, with an average work experience of 10.88 ± 7.21 years. Among head nurses, 100% were female, with a mean age of 46.13 ± 3.29 years and an average managerial experience of 3.0 ± 2.63 years (Table 1).

Table 1.

Demographic characteristics of nurses and head nurses participating in the study

Variable	Categories	Nurses (n = 381)	Head Nurses (n = 30)
		(Mean ± SD, years)	(Mean ± SD, years)
Age		35.04 ± 7.65	46.13 ± 3.29
Work Experience		10.88 ± 7.20	21.7 ± 3.73
Managerial Experience		-	3.0 ± 2.63
		n (%)	n (%)
Gender	Male	77(20.2)	0(0)
	Female	304(79.6)	30(100)
Marital Status	Single	83(21.8)	1(3.3)
	Married	298(78.2)	29(96.7)
Education	Bachelor’s	343(89.8)	25(83.3)
	Master’s or higher	38(9.9)	5(16.7)

Note: Continuous variables are presented as the mean ± standard deviation, and categorical variables as numbers (percentages)

Using the LEAD questionnaire, the most frequently reported leadership style among head nurses was Supporting (S3) (31.17%), followed by Coaching (S2) (25.0%). The Directing (S1) and Delegating (S4) styles were less common, accounting for 22.77% and 21.12%, respectively. Nurses’ perceptions of their head nurses’ leadership styles, as assessed by the other-assessment LEAD, showed a similar, though not identical, trend. Specifically, Coaching (S2) was the most prevalent (27.45%), followed by Supporting (S3) (26.33%). The Delegating (S4) and Directing (S1) styles were less common, accounting for 24.51% and 21.57%, respectively (Table 2).

The mean job satisfaction scores among nurses, measured using the Warr-Cook-Wall Job Satisfaction Scale, were 58.54 ± 11.95, indicating a relatively high level of satisfaction.

Hierarchical regression analysis was conducted to predict nurses’ job satisfaction based on head nurses’ leadership styles, while controlling for age, education level, and work experience. The overall model explained only 2% of the variance in job satisfaction scores (R² = 0.02, Adjusted R² ≈ 0.00) and was not statistically significant (p = 0.395), indicating very low explanatory power. In the first step, only the control variables were entered into the model. This model was not statistically significant, F (3, 377) = 0.61, p = 0.609, and accounted for a negligible proportion of the variance in job satisfaction (R² = 0.01, adjusted R² = -0.00). None of the control variables were significant predictors (all p > 0.05). In the second step, the four leadership styles were added to the model. The full model was also not found to be statistically significant, F (7, 373) = 1.05, p = 0.395, with an explained variance close to zero (R² = 0.02, adjusted R² = 0.00). The change in R² after adding the leadership styles was minimal (ΔR² = 0.01) and not significant (F change = 1.05, p = 0.395). Notably, the Directing (b = -0.081, p > 0.05), Coaching (b = -0.057, p > 0.05), Supporting (b = -0.058, p > 0.05), and Delegating (b = -0.066, p > 0.05) leadership styles did not show any statistically significant association with nurses’ job satisfaction. Overall, these results indicate that neither the control variables nor the perceived leadership styles of head nurses significantly predict job satisfaction in this sample (Table 3). Assumption checks confirmed that all hierarchical regression models met the criteria for linearity, homoscedasticity, normality of residuals, and absence of influential outliers.

Table 3.

Multiple regression analysis of demographic variables and leadership styles in relation to nurses’ job satisfaction (N = 381)

Predictors		Model 1: Control		Model 2: Full Model
		B (SE)	β	B (SE)	β	95% CI for B
Control Variables	Age	0.01 (0.20)	0.003	0.06 (0.20)	0.035	–0.38 to 0.40
	Education	0.89 (2.03)	0.022	0.70 (2.07)	0.018	–3.09 to 4.68
	Work Experience	0.10 (0.20)	0.062	0.06 (0.21)	0.034	–0.35 to 0.47
Leadership Styles	Directive (S1)	--		-0.81 (1.32)	− 0.081	–3.38 to 1.76
	Coaching (S2)	--		-0.57 (1.33)	− 0.057	–3.18 to 2.04
	Supporting (S3)	--		-0.58 (1.32)	− 0.058	–3.16 to 2.00
	Delegative (S4)	--		-0.66 (1.31)	− 0.066	–3.23 to 1.91
Model Fit	R²	0.01		0.02
	Adjusted R²	− 0.00		0.00
	F for model change (df1, df2)	0.61 (3, 377)		0.90 (4, 373)
	ΔR²	--		0.01

Note1. Neither the demographic control variables (age, education, work experience) nor any of the four leadership styles (Directive, Coaching, Supporting, Delegating) were statistically significant predictors (p > 0.05), explaining only 2% of the variance (adjusted R²≈0.00)

Note2: Model 1: F (3, 377) = 0.61, p = 0.609; Model 2: F (4, 373) = 0.90, p = 0.395. SE = standard error; β = standardized beta. 95% confidence intervals for each coefficient are shown

Discussion

This study examined the relationship between head nurses’ leadership styles and nurses’ job satisfaction in hospitals affiliated with Kerman University of Medical Sciences. The Coaching (S2) and Supporting (S3) leadership styles were the most prevalent among head nurses. Our findings did not support the hypothesized positive relationship; none of the leadership styles showed a statistically significant association with job satisfaction. These findings contrast with much of the existing evidence, which highlights positive associations between leadership styles and job satisfaction.

Several systematic reviews and meta-analyses have shown that leadership styles such as transformational, authentic, and servant leadership are closely associated with job satisfaction and nurse retention. In contrast, leaders who adopt task-focused or authoritarian styles are associated with lower job satisfaction among nursing staff [20, 29, 52]. For example, a systematic review found a positive association between leadership style and nurse job satisfaction, with 88% of the studies reporting a significant positive relationship. Transformational leadership was identified as the most effective style [29]. The non-significant regression results, contrasting with broader literature findings, can be contextualized by specific organizational constraints and participant characteristics documented in our study setting. Head nurses had limited managerial experience (M = 3.0 ± 2.63 years; Table 1), potentially restricting their ability to develop consistent, impactful leadership styles that effectively influence staff satisfaction.

Beyond leadership, none of the demographic variables—age (β = 0.01, p = 0.609), education (β = 0.89, p = 0.609), or work experience (β = 0.10, p = 0.609)—significantly predicted nurses’ job satisfaction. In this sample, the age range was relatively narrow (mean = 35.4 ± 7.65 years), and the overwhelming majority held a bachelor’s degree (89.8%), limiting variability and reducing the statistical power to detect relationships. Furthermore, as indicated in prior literature from similar settings, head nurses often operate within centralized structures with limited autonomy over key personnel decisions [53]. In the context of Iranian teaching hospitals, organizational factors such as high workload, low salary, limited autonomy, job insecurity, perceived lack of organizational support, and restricted managerial authority appear to strongly influence nurses’ job satisfaction. These factors, combined with cultural differences, may reduce the overall impact of leadership [54].

The Iranian hospital environment is characterized by a hierarchical culture and strong physician authority [55, 56], which limits head nurses from fully implementing empowering Coaching (S2) and Supporting (S3) leadership styles. Because head nurses often lack the organizational authority to act on staff input, their supportive efforts may be perceived as merely symbolic, weakening any direct correlation between leadership style and nurses’ job satisfaction. Systemic challenges—such as chronic staffing shortages, limited financial resources, and a work environment primarily focused on basic concerns like workload and safety—further constrain the effectiveness of supportive leadership in addressing the main sources of dissatisfaction [27, 57], creating a ceiling effect that obscures statistical relationships. Additionally, cultural expectations and a historical emphasis on formality make directive leadership the norm, while supportive styles may be resisted or undervalued [58]. Job satisfaction is influenced by perceptions of fairness, status, and equity within nurse-physician relationships [59]. Feelings of injustice stemming from undervalued roles, income disparities, or overlooked contributions persist even under supportive leadership [60]. Concurrently, our sample exhibited high mean job satisfaction scores, indicating the presence of a ceiling effect that reduced variance and hindered the detection of any significant association with leadership styles [52]. Evidence suggests that leadership likely influences satisfaction indirectly through structural empowerment, organizational justice, autonomy, and perceived support—factors that have a greater impact than the direct effects of leadership style [33, 61–63]. However, existing literature highlights the critical role of competent leadership in helping nurses maintain a healthy work-life balance, enhance patient care, and reduce turnover rates [64–66]. Leadership practices that involve nurses in decision-making, recognize their efforts, and promote autonomy are transformational and empowering. Such practices are linked to reduced burnout, increased engagement, and improved quality of care [67, 68]. Healthy work environments depend on adaptive and supportive leaders [52]. Therefore, it is essential to develop leaders’ diagnostic and adaptive capabilities within a situational context.

Existing research conducted in similar cultural and healthcare settings supports the notion that the work environment predominantly impacts nurses’ quality of life and professional satisfaction. Recent research has found that work environment factors, more than leadership behaviors, largely determine the professional quality of life for nurses in neonatal care units [69]. Another study reported that contextual instability and organizational limitations had a greater influence on stress and resilience among nursing students than support [45]. These findings align with the results of the present study, which highlight that environmental and structural components may outweigh leadership style as sources of job satisfaction. Furthermore, nurse well-being is a complex concept influenced by emotional, demographic, and organizational factors. According to Aqtam et al. (2025), emotional intelligence and work engagement are the most significant predictors of satisfaction and performance among nurses [46]. All of these studies reinforce the thesis that the relationship between leadership style and job satisfaction is highly context-specific and moderated by broader environmental and structural variables—a phenomenon also observable in the Iranian healthcare setting. The lack of a significant relationship between leadership style and job satisfaction observed in the present study reflects the influence of structural and contextual factors within Iranian teaching hospitals. It is crucial to address these organizational challenges comprehensively, alongside developing leadership capacity, to achieve sustainable improvements in nurse satisfaction, retention, and the quality of patient care.

As a post-hoc interpretation, the non-significant findings can be viewed through the lens of Situational Leadership (SL) theory [37, 70]. While SL emphasizes adapting style to follower readiness, the prevalent organizational constraints in our setting (e.g., high workload, limited managerial authority) may have created a context where even appropriately chosen leadership behaviors (such as the prevalent Coaching and Supporting styles) had a limited direct impact on job satisfaction. This perspective suggests that future interventions may need to first address these systemic barriers to create an environment where adaptive leadership can translate into improved staff outcomes.

This study found no significant direct relationship between head nurses’ leadership styles and job satisfaction within the examined context. Although supporting and coaching styles were prevalent, their impact may have been moderated by factors such as leaders’ limited managerial experience, high baseline satisfaction levels, and the critical influence of organizational conditions. Given the absence of a direct effect, we interpret leadership as operating indirectly through structural empowerment, organizational justice, and perceived support. Therefore, future research would benefit from longitudinal or intervention-based studies to better understand how well a leadership style must align with its specific context to be truly effective. Such studies should also incorporate mediating and moderating variables, including empowerment, organizational culture, organizational justice, and perceived organizational support. Leadership development programs should focus not only on leadership style but also on encouraging and empowering work environments and enhancing leaders’ adaptive skills. These programs are recommended to improve both staff well-being and patient outcomes. Implementing such strategies could help clarify the complex interplay between leadership and job satisfaction.

Limitations

Several limitations should be considered when interpreting the findings of this study. First, the cross-sectional design limits causal inference, as leadership styles and job satisfaction were assessed at a single point in time. Second, although all eligible head nurses were included using a census approach, the relatively small sample size (n = 30) may have reduced the statistical power to detect leadership effects. Third, the study was conducted in teaching hospitals affiliated with a single university in southeastern Iran, which may limit the generalizability of the findings to other healthcare settings with different organizational or cultural characteristics. Fourth, reliance on self-reported questionnaires introduces the potential for social desirability and common-source bias, which may have influenced perceptions of both leadership behaviors and job satisfaction. Fifth, while the LEAD instrument is a validated tool, categorizing leadership into four discrete styles may oversimplify the dynamic and context-dependent nature of leadership behaviors in clinical environments. Sixth, nurse sampling was not stratified by unit or shift, raising the possibility of unmeasured clustering effects. Finally, the low proportion of variance explained by the regression models suggests that key determinants of job satisfaction—such as workload, organizational support, autonomy, and workplace relationships—were not captured in the present analysis. Future research employing longitudinal or mixed-methods designs and incorporating mediating and contextual variables is warranted to better elucidate the pathways linking leadership and nurse job satisfaction in resource-constrained settings.

Conclusion

While theory predicts that effective leadership enhances nurse satisfaction, our empirical data did not confirm this relationship in teaching hospitals affiliated with Kerman University of Medical Sciences. Leadership development programs should emphasize adaptive competencies—such as situational assessment, empowerment, and diagnostic skills—rather than promoting a single leadership style. This approach enables emerging head nurses to translate supportive behaviors into improvements in staff well-being. Interestingly, nurses reported moderate overall satisfaction. The findings suggest that organizational factors and situational context may have a greater influence on satisfaction than leadership style. Additionally, many head nurses have limited management experience, which may affect their effectiveness. Organizational policy must address structural barriers by granting clearer decision-making authority, enforcing safe nurse-to-patient ratios, and establishing systematic feedback mechanisms. These measures create an environment where effective leadership can positively impact satisfaction. Integrating targeted leadership training with systemic reforms offers the most promising pathway to enhance nurse satisfaction and retention in resource-constrained teaching hospitals. Future studies should explore the indirect effects of leadership, focusing on key mediators such as empowerment, a supportive culture, and perceived organizational support.

Abbreviations

LEAD

Leader Effectiveness and Adaptability Description

Author contributions

MHK, RSN, and RMR contributed to conceiving and designing the research. The data were collected, analyzed, and interpreted by MHK, RSN, and RMR. MHK and RMR contributed equally in writing and revising the manuscript and approved it. All authors have read and approved the final manuscript.

Funding

This research received no specific grants from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The data are available upon request to the corresponding author after signing appropriate documents in line with ethical applications and the decision of the ethics committee.

Declarations

Ethics approval and consent to participate

The present study was approved by the Ethics Committee of Kerman University of Medical Sciences (Approval No. 402000619; IR.KMU.REC.1402.367). All steps and procedures adhered to the Declaration of Helsinki and the Committee on Publication Ethics (COPE). Written informed consent was obtained from all participants before their involvement in the study. The consent form detailed the study’s purpose, procedures and emphasized that participation was entirely voluntary. Participants were explicitly informed of their right to withdraw at any time without penalty or impact on their employment. To ensure confidentiality and privacy, all collected data were anonymized. Participants’ identities were replaced with unique codes, and any identifying information was stored separately from the research data under secure conditions. Data protection was maintained by storing all electronic files on a password-protected computer, while hard copies were kept in a locked cabinet accessible only to the research team. Formal permission to use the data collection instruments (the LEAD questionnaire and the Warr-Cook-Wall job satisfaction scale) was secured, and their use complied with the terms of the licenses. The study protocol and consent procedures were also approved by the administrative authorities of the hospitals involved, from whom necessary permissions were obtained before data collection began.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.