The Unseen Side of Nursing Leadership: Conceptualizing Leadership Blind Spots in Healthcare Settings

ABSTRACT

Background

Nursing leadership effectiveness depends not only on clinical expertise and formal authority but on the capacity to perceive how one's own conduct is experienced by staff. Leadership blind spots—unrecognized gaps between a nurse leader's self‐perception and the actual impact of their behaviour on staff voice, trust, and psychological safety—represent a consequential and theoretically underdeveloped phenomenon in nursing management. Left unrecognized, these gaps may silently undermine staff well‐being, patient safety, and organizational culture.

Aim

To clarify and conceptually define leadership blind spots in nursing using Walker and Avant's concept analysis framework, identify their defining attributes, antecedents, consequences, and empirical referents, and propose a Leadership Blind Spot Pathway Model and recommendations for measurement, practice, and policy.

Methods

Walker and Avant's eight‐step concept analysis framework was applied. A structured literature search was conducted across six electronic sources—PubMed, CINAHL, Scopus, PsycINFO, Web of Science, and Google Scholar—covering publications from 2020 to 2025 and supplemented by foundational theoretical works. From an initial pool of 58 records, 30 sources were retained for analysis following duplicate removal and two‐stage screening.

Results

A nursing leadership blind spot is proposed as a recurring and insufficiently recognized discrepancy between a nurse leader's self‐perceived behaviour and how that behaviour is experienced by staff. Four core defining attributes were identified: self–other perceptual discrepancy, limited recognition and integration of corrective feedback, miscalibrated confidence in leadership judgement, and relational‐contextual unawareness of leadership impact. These attributes are clinically expressed through six manifestations—communication, fairness, emotional, power, performance, and change‐related blind spots. Antecedents operate at individual, contextual, and organizational levels; consequences extend to nurse leaders, nursing staff, patients, and healthcare organizations. A Leadership Blind Spot Pathway Model incorporating a self‐reinforcing feedback loop is proposed, in which staff silence both reflects and perpetuates leader unawareness. The concept is distinguished from destructive leadership, incompetence, burnout, and related constructs by the combination of a self–other perceptual discrepancy and limited recognition of that discrepancy.

Conclusion

Leadership blind spots represent a potentially distinct and operationalizable construct in nursing that warrants empirical validation. Embedding multisource feedback, reflective practice, and psychological safety into leadership development represents a promising, though not yet empirically tested, pathway to their detection and reduction. Development and psychometric validation of a Nursing Leadership Blind Spot Scale is recommended as a research priority.

1. Introduction

Nursing leadership occupies a pivotal position in the architecture of healthcare quality. The behaviours, decisions, and relational practices of nurse leaders directly shape staff engagement, psychological safety, workplace culture, and, ultimately, patient outcomes (Mohammad et al. 2023; Abou Hashish 2024). A growing body of evidence confirms that transformational, authentic, and relational leadership styles foster nurse well‐being, organizational resilience, and quality care delivery (Abd‐El Aliem and Abou Hashish 2021; Abou Hashish et al. 2023). Yet, despite decades of investment in nursing leadership development, a persistent and troubling reality endures: nurse leaders with good intentions, genuine commitment, and formal competence may still cause harm through behaviours they themselves fail to perceive.

This invisible dimension of leadership dysfunction is increasingly recognized in organizational psychology and management science as the phenomenon of leadership blind spots—the systematic and often unrecognized gaps between how leaders believe they are leading and how their conduct is actually experienced by those they lead (Eurich 2017; Dunning et al. 2003; Bilderback 2025). In nursing, where leadership operates within hierarchical structures, high‐stakes clinical environments, and complex interprofessional dynamics, the consequences of unchecked blind spots extend beyond individual relationships to encompass staff burnout, silence, disengagement, turnover intention, and threats to patient safety (Hult et al. 2023; Lee, Seo, and Squires 2024).

Unlike overt leadership failures, such as abusive supervision or ethical violations, blind spots are characterized precisely by their imperceptibility to those who hold them. Nurse managers may believe that they communicate clearly when staff feel persistently dismissed. Unit managers may regard their performance evaluations as objective while nurses perceive favouritism (Lee, Seo, and Squires 2024). Charge nurses may view themselves as emotionally available while colleagues experience them as cold and task‐driven. The danger resides not in malice, but in unawareness—and the institutional cultures that permit this unawareness to persist unexamined (Yukl and Gardner 2020; Mrayyan et al. 2023; Robinson‐Walker 2008).

Existing nursing leadership frameworks, including authentic leadership and transformational leadership, emphasize a leader's values, vision, and relational behaviours, but they do not explicitly account for situations in which a leader's self‐perceived enactment of these qualities diverges from how staff actually experience them (Mohammad et al. 2023; Abd‐El Aliem and Abou Hashish 2021; Abou Hashish et al. 2023). A leader can score highly on self‐report measures of authentic or transformational leadership while remaining unaware that specific behaviours are experienced by staff as dismissive or inequitable. Leadership blind spots therefore describe a metaperceptual layer that existing leadership‐style frameworks are not designed to detect. This gap is particularly consequential in nursing and other healthcare settings, where hierarchical clinical structures, continuous shift‐based communication, and the acuity of patient‐safety consequences make the timely correction of leader–staff perception gaps more urgent than in many other organizational contexts (Hult et al. 2023; Cummings et al. 2021).

Despite its relevance, the concept of leadership blind spots has received limited scholarly attention in the nursing literature (Robinson‐Walker 2008). Based on the literature search undertaken for this analysis, no nursing‐specific concept analysis of leadership blind spots or validated nursing‐specific measure of the construct was identified. Previous nursing scholarship has, however, demonstrated the value of concept analysis for clarifying leadership phenomena more broadly: using Walker and Avant's approach, Qtait identified self‐development, teamwork, nursing excellence, creative problem‐solving, and influence as attributes of nursing leadership, providing an important foundation for continued conceptual refinement of leadership within the profession (Qtait 2023). The present analysis extends this line of inquiry by focusing not on the attributes of effective nursing leadership itself, but on the less visible self–other perceptual discrepancies that may occur within leadership practice, regardless of a leader's overall style or competence. The present study seeks to address this gap through a rigorous application of Walker and Avant's concept analysis methodology, with the aim of clarifying the concept of leadership blind spots in nursing, proposing its defining attributes and theoretical foundations, and offering an integrated model to guide future research, practice, and policy.

1.1. The Significance of the Study

Examining leadership blind spots has important implications for nursing leadership, workforce well‐being, psychological safety, and patient care. Healthcare systems worldwide face mounting pressures from nursing workforce shortages, high rates of burnout, and persistent challenges to psychological safety and staff voice (Hult et al. 2023; Alhalal et al. 2024). Concurrently, nursing leadership development programs have disproportionately focused on visible competencies—strategic thinking, clinical knowledge, financial acumen—while the subtler dimensions of self‐awareness and interpersonal impact have received considerably less sustained attention (Lee, Seo, and Macphee 2024; Cummings et al. 2021). This imbalance creates an organizational environment in which leadership behaviours that staff experience as harmful may go unaddressed because leaders genuinely do not perceive their own contribution to staff distress.

Research from organizational behaviour suggests that leaders who overestimate their interpersonal effectiveness and underestimate the chilling effect of their authority on honest staff communication may represent a common rather than an exceptional pattern (Eurich 2017). The Dunning–Kruger effect provides one theoretical lens for understanding how limitations in self‐assessment may coexist with confidence in one's judgement, although its application to nursing leadership requires empirical testing (Dunning et al. 2003). This dynamic may be intensified in nursing, where hierarchical power differentials, professional socialization toward deference, and the relentless pressure of clinical practice create conditions particularly inhospitable to candid upward feedback (Edmondson 2018).

Furthermore, the consequences of unchecked leadership blind spots ripple outward in ways that carry both ethical and institutional weight (Robinson‐Walker 2008; Edmondson 2018). Staff who experience their leaders as dismissive, unfair, or emotionally absent are significantly more likely to disengage, withhold safety‐relevant information, experience burnout, and ultimately leave the profession (Hult et al. 2023; Lee, Seo, and Squires 2024; Conger 2024). These downstream effects impose substantial costs on patients, teams, and healthcare organizations. A conceptual framework for leadership blind spots in nursing thus fills an important scholarly and practical void, providing the terminological, theoretical, and empirical scaffolding necessary for evidence‐based intervention.

1.2. Aim of the Study

The primary aim of this concept analysis is to explore and clarify the meaning and determinants of leadership blind spots within the context of nursing practice and healthcare management. Specifically, this analysis seeks to propose a definition of the concept, identify its defining attributes, antecedents, and consequences, construct illustrative cases, and propose a theoretical model and empirical referents to guide future scholarship and nursing leadership development.

2. Methods

2.1. Design

This concept analysis was conducted using Walker and Avant's (2011) eight‐step framework, a methodology widely employed in nursing scholarship to clarify abstract or emerging concepts, develop theoretical foundations, and support future empirical applications (Abou Hashish 2024; Abd‐El Aliem and Abou Hashish 2021). The eight steps are: (1) selecting a concept for analysis; (2) determining the aims or purposes of the analysis; (3) identifying all uses of the concept; (4) determining its defining attributes; (5) constructing a model case; (6) constructing borderline, related, contrary, and additional cases; (7) identifying antecedents and consequences; and (8) defining empirical referents (Walker and Avant 2011). Figure 1 illustrates this eight‐step framework as applied in the present study.

FIGURE 1.

Walker and Avant's eight‐step framework.

2.2. Literature Review

A structured literature search was conducted across six databases—PubMed, CINAHL, Scopus, PsycINFO, Web of Science, and Google Scholar—supplemented by a review of organizational behaviour textbooks, nursing leadership reports, and reputable web‐based resources. Search terms included combinations of ‘leadership blind spot*,’ ‘nurse leader* self‐awareness,’ ‘leadership overconfidence,’ ‘psychological safety’ AND ‘nursing,’ ‘nurse manager’ AND ‘feedback,’ ‘staff voice,’ ‘organizational justice’ AND ‘nursing,’ ‘workplace incivility’ AND ‘nursing,’ ‘inclusive leadership,’ ‘leader humility,’ ‘moral courage’ AND ‘nurse leader*,’ ‘leader‐member exchange’ AND ‘nursing,’ and ‘nursing leadership derailment,’ combined using Boolean operators (AND/OR) and, where applicable, Medical Subject Headings (MeSH). Database‐specific search strategies and applied limits are provided in File S1 to enhance transparency and reproducibility of the literature search.

Publications from 2020 to 2025 were prioritized, supplemented by foundational theoretical and empirical works regardless of publication date. Inclusion criteria comprised English‐language, peer‐reviewed publications (supplemented by seminal books and reputable grey literature for foundational theoretical works) that directly addressed leadership self‐awareness, self–other perception gaps, feedback receptivity, psychological safety, or staff voice in nursing or comparable healthcare contexts. Records were excluded if they addressed leadership exclusively in non‐healthcare settings without conceptual transferability, focused on management topics unrelated to self‐awareness or feedback, or were unavailable in English. Records were screened by the author in two stages: first by title and abstract and subsequently through full‐text eligibility assessment; reasons for full‐text exclusion were documented at each stage. Single‐author screening is acknowledged as a limitation (see Strengths and Limitations).

From an initial pool of 58 records identified across the six databases, 30 sources were retained for concept analysis following duplicate removal and two‐stage screening (title and abstract, followed by full‐text review), comprising 24 peer‐reviewed journal articles, 4 books, and 2 web‐based scholarly resources (Figure 2). Attributes, antecedents, consequences, and empirical referents were extracted from each retained source using a structured data‐extraction approach and synthesized iteratively across sources through constant comparison, consistent with established concept‐analysis methodology (Walker and Avant 2011). A number of additional references cited elsewhere in this manuscript (e.g., the author's own related concept‐analysis and empirical work on digital leadership and compassion) provide contextual or comparative background rather than forming part of the 30‐source analytic corpus; they are cited where directly relevant but are not double‐counted in the literature‐selection totals above.

FIGURE 2.

Source identification and selection process supporting the concept analysis.

3. Results

3.1. Selecting a Concept and Determining Its Purpose

The first step of Walker and Avant's framework requires selecting the concept and defining its purpose for analysis (Walker and Avant 2011). Leadership blind spots were chosen due to their growing relevance to nursing leadership practice, their significant yet undertheorized consequences for staff and patient outcomes, and the absence of a published concept analysis or validated measurement tool addressing this phenomenon in nursing. The concept derives from established organizational behaviour literature but has not yet been systematically examined within the distinct context of nursing leadership, where unique power dynamics, professional hierarchies, and high‐stakes clinical environments shape both the emergence and the consequences of blind spots in ways not captured by existing general models (Eurich 2017; Dunning et al. 2003; Robinson‐Walker 2008).

The purpose of this analysis is to establish a conceptual foundation for understanding leadership blind spots in nursing, distinguishing this concept from adjacent phenomena such as leadership incompetence, intentional harm, or general burnout. By proposing its attributes and grounding it in theory, this analysis provides a basis for measurement tools, educational interventions, and organizational policies that can address the invisible harms that may occur when nurse leaders fail to perceive the gap between their intentions and their impact on staff.

3.2. Identifying All the Uses of the Concept

The concept of leadership blind spots originates at the intersection of cognitive psychology, organizational behaviour, and leadership science. The term ‘blind spot’ was originally derived from visual neuroscience, where it refers to the area of the retina lacking photoreceptors, creating a gap in visual perception that the brain automatically compensates for, rendering the deficit largely unnoticed by the individual. More broadly, a blind spot refers to an area that remains outside visibility or cannot be adequately recognized using available means or perspectives. Conceptually, it also denotes a limitation in awareness, judgement, or perception in which individuals fail to recognize important realities, consequences, or viewpoints despite their presence (Merriam‐Webster 2026). Applied metaphorically to leadership, a blind spot reflects dimensions of a leader's own behaviour, interpersonal impact, communication style, or relational dynamics that exist beyond the leader's perceptual awareness, often obscured by the same cognitive and emotional processes that normally support self‐evaluation and leadership judgement (Dunning et al. 2003; Yukl and Gardner 2020).

In organizational psychology, blind spots have been discussed in relation to the Johari Window framework, originally proposed by Luft and Ingham (1955) as a model of interpersonal awareness. The Johari Window describes four quadrants of self‐knowledge: open (known to self and others), blind (known to others but not to self), hidden (known to self but not others), and unknown (unknown to both). The ‘blind’ quadrant maps directly onto the concept of interest, representing information about a leader's behaviour that staff observe and experience but that the leader does not perceive (Luft and Ingham 1955). Eurich (2017) extended this framework in her empirical research on self‐awareness, distinguishing between internal self‐awareness (how we see ourselves) and external self‐awareness (how others see us), and demonstrating that leadership effectiveness correlates far more strongly with external self‐awareness than leaders typically recognize (Eurich 2017).

Within healthcare management, the term has been applied to organizational decision‐making failures and the tendency of senior leaders to misread the psychological climate of their teams (Yukl and Gardner 2020; Mrayyan et al. 2023; Robinson‐Walker 2008). In nursing specifically, while the term ‘blind spot’ has not been formally conceptualized or operationalized, its phenomenological reality is documented under adjacent labels: leadership behaviours that staff experience as dismissive despite leaders' contrary self‐assessments, perceived favouritism that leaders deny, psychological unsafety that leaders attribute to staff rather than to their own conduct, and a persistent disconnect between leadership self‐perception and staff‐reported experience (Hult et al. 2023; Lee, Seo, and Squires 2024; Robinson‐Walker 2008; Cummings et al. 2021).

The concept also finds resonance in discussions of leadership derailment—a body of literature describing the failure of otherwise capable leaders due to interpersonal blind spots, inability to adapt, and failure to build relationships (Yukl and Gardner 2020). Hogan and Hogan's foundational work on dark‐side leadership traits identified overconfidence, emotional insensitivity, and resistance to feedback as core derailment mechanisms applicable across professional leadership contexts (Hogan et al. 2011). These threads, drawn together, constitute the conceptual landscape from which a nursing‐specific understanding of leadership blind spots can be developed.

3.3. Theories and Models Supporting the Concept

Several established theoretical frameworks provide the intellectual scaffolding for understanding leadership blind spots in nursing. Although no single theory was developed specifically to address this concept, the following frameworks collectively illuminate its mechanisms, antecedents, and consequences.

The Johari Window Model (Luft and Ingham 1955), as the most directly applicable framework, conceptualizes the blind quadrant as behaviours and characteristics known to others but invisible to the self. In nursing leadership, this quadrant corresponds precisely to the space where leadership blind spots reside: where staff perceive dismissiveness, inequity, or emotional unavailability that the nurse leader genuinely does not recognize. Reducing the blind quadrant requires deliberate exposure to honest feedback and cultivation of a relational environment in which such feedback can safely emerge.

The Dunning–Kruger Effect (Dunning et al. 2003), a cognitive bias in which individuals with limited competence in a domain may overestimate their performance, has been applied beyond its original cognitive domain to leadership self‐assessment (Dunning et al. 2003). Applied cautiously to leadership, this framework suggests that limitations in self‐assessment may coexist with high confidence in perceived relational effectiveness, potentially contributing to the persistence of unrecognized discrepancies between self‐perception and external experience. In nursing leadership, this perspective offers a possible explanation for why some nurse managers may not recognize the need for developmental feedback or may have difficulty integrating corrective feedback when it challenges established self‐perceptions. This proposed mechanism requires direct empirical testing in nursing leadership contexts.

Edmondson's Psychological Safety Theory (Edmondson 2018) argues that teams perform at their highest when members believe they can speak up, share concerns, and admit mistakes without fear of interpersonal punishment from their leaders. Leadership blind spots may be closely linked to failures in psychological safety: when a nurse manager is unaware that their communication style, emotional expressions, or responses to dissent create a climate of fear, staff silence ensues, and the leader receives no corrective signal. The resulting feedback vacuum reinforces the blind spot rather than challenging it (Edmondson 2018).

Rock's SCARF Model (Rock 2008) identifies five social domains—Status, Certainty, Autonomy, Relatedness, and Fairness—that neuroscience has linked to threat and reward responses in social environments. Leadership blind spots often operate through one or more of these domains: a leader who unconsciously diminishes staff status through public criticism, creates uncertainty through inconsistent communication, restricts autonomy through micromanagement, erodes relatedness through emotional distance, or violates fairness through differential treatment (Rock 2008; Guarnier and Chimenti 2024).

Nembhard and Edmondson's  (Nembhard and Edmondson 2006; Nikpour et al. 2022) work on leader inclusiveness further demonstrates that when leaders are unaware of how their authority inhibits honest staff communication, the psychological safety necessary for clinical learning, error reporting, and care improvement is systematically suppressed. This framework positions nursing leadership blind spots not merely as an interpersonal issue but as a systems‐level patient‐safety concern. Walker and Avant's concept analysis framework (Walker and Avant 2011) itself provides the methodological architecture for this study, ensuring that leadership blind spots are systematically distinguished from related but distinct phenomena, grounded in existing theory, and positioned within a clearly articulated conceptual context.

Table 1 synthesizes how these frameworks converge on a common underlying mechanism—perceptual miscalibration sustained by a compromised feedback environment.

TABLE 1.

Convergence of theoretical frameworks supporting leadership blind spots in nursing.

Theoretical framework	Core mechanism	Contribution to the leadership blind spot model	Point in the proposed pathway
Johari Window (Luft & Ingham)	The ‘blind’ quadrant: information known to others but not to the self	Names the core perceptual gap that defines the concept and gives it its label	Perceptual miscalibration (origin)
Dunning–Kruger Effect	Limited competence or insight in a domain is paired with disproportionately high confidence in that domain	Offers a possible explanation for how limitations in self‐assessment may coexist with high confidence in leadership judgement	Miscalibrated confidence
External self‐awareness (Eurich)	Distinguishes internal self‐awareness (how leaders see themselves) from external self‐awareness (how others see them)	Provides the empirical basis for treating self–other discrepancy as measurable rather than purely theoretical	Perceptual miscalibration
Psychological Safety Theory (Edmondson)	Team members withhold voice, concerns, and mistakes when they perceive interpersonal risk in speaking up	Explains why corrective feedback fails to reach the leader, sustaining the perceptual gap	Feedback deprivation
Leader inclusiveness (Nembhard & Edmondson)	Specific leader behaviours invite or suppress staff voice within clinical teams	Links leader behaviour directly to whether feedback channels stay open or close	Feedback deprivation
SCARF Model (Rock)	Status, Certainty, Autonomy, Relatedness, and Fairness function as neural threat/reward domains in social interaction	Identifies the relational domains through which leader behaviour is experienced and evaluated by staff	Manifestation/staff experience
Leadership derailment (Hogan & Hogan)	Overconfidence, emotional insensitivity, and resistance to feedback drive senior‐leader failure over time	Describes the long‐term trajectory when blind spots remain uncorrected	Consequence

Rather than treating these frameworks as competing explanations, the present analysis positions them along different points of a single conceptual pathway. External self‐awareness and self‐assessment theories help explain perceptual miscalibration; psychological safety and leader‐inclusiveness theories help explain access to corrective feedback; and the SCARF model identifies the relational domains in which discrepancies become experienced by staff. Their convergence supports a relational model in which leadership blind spots emerge from the interaction between leader perception and the surrounding feedback environment—an integration reflected directly in the structure of the Leadership Blind Spot Pathway Model (Figure 3).

FIGURE 3.

Leadership blind spot pathway model.

3.4. Defining Attributes of Leadership Blind Spots in Nursing

Defining attributes are the essential and distinguishing characteristics of a concept that together constitute its core identity and differentiate it from related but distinct phenomena (Walker and Avant 2011). The analysis was refined to four defining attributes that are individually necessary and collectively sufficient to identify the concept. The previously proposed attributes of inequitable practice and favouritism, emotional disconnection, and inattention to staff silence are retained in this revision as clinically observable manifestations of these four core attributes rather than as independently defining characteristics (Table 2).

TABLE 2.

Typologies and manifestations of leadership blind spots in nursing.

Manifestation (type)	Associated core attribute(s)	Leader self‐perception	Staff experience	Clinical manifestation
Communication blind spot	Attributes 1 & 2	Believes communication is clear, direct, and transparent	Messages feel dismissive, ambiguous, or intimidating	Staff seek clarification from peers; concerns go unshared with the leader
Fairness & equity blind spot	Attributes 1 & 4	Perceives their decisions as objective and consistent	Observes favouritism in scheduling, recognition, and discipline	Disillusionment, reduced cohesion, increased grievances
Emotional blind spot	Attribute 4	Considers themselves self task‐focused and efficient	Experienced as cold, unavailable, or dismissive of distress	Staff normalize suffering; moral distress and burnout go unaddressed
Power blind spot	Attributes 2 & 4	Views their position as a resource for staff, not a barrier	Authority creates fear that inhibits honest upward communication	Patient‐safety concerns withheld; errors go unreported
Performance blind spot	Attributes 1 & 3	Believes recognition is merit‐based and comprehensive	Quiet, consistent contributors feel invisible and undervalued	Loss of high performers; erosion of intrinsic motivation
Change blind spot	Attributes 3 & 4	Sees themselves as a progressive, visionary change driver	Change experienced as imposed without consultation or readiness assessment	Passive resistance, implementation failure, change fatigue

3.5. Attribute 1: Self–Other Perceptual Discrepancy

The foundational and organizing attribute of leadership blind spots is a measurable discrepancy between a nurse leader's self‐perception of their own behavioural impact and how that impact is experienced or reported by staff, peers, or the broader unit (Eurich 2017). This discrepancy is not equivalent to global incompetence; rather, it reflects a targeted gap in external self‐awareness—the understanding of how one's leadership behaviours are experienced by others, as distinct from internal self‐awareness (Eurich 2017). Nurse leaders with this attribute may perceive themselves as effective communicators, fair decision‐makers, and emotionally present supervisors while staff consistently report experiences that contradict these self‐assessments. The gap may be reinforced by cognitive mechanisms, including confirmation bias and self‐serving attribution, that shape how feedback is interpreted (Dunning et al. 2003). In nursing units, this manifests as leaders who interpret high staff turnover as a workforce quality problem rather than a leadership signal, or who attribute staff disengagement to clinical fatigue rather than to their own managerial conduct.

3.6. Attribute 2: Limited Recognition and Integration of Corrective Feedback

A second defining attribute is the leader's limited capacity to recognize, receive, and integrate corrective feedback from staff, peers, or organizational systems into their self‐assessment. This does not necessarily reflect explicit rejection of feedback; rather, it encompasses the range of mechanisms through which feedback fails to penetrate the leader's self‐concept, including minimizing the validity of feedback (‘they are just complaining’), attributing critical input to the source's personal motivation, selectively attending to affirming rather than corrective signals, and structuring interactions in ways that reduce the likelihood of honest upward communication (Cummings et al. 2021). In nursing settings characterized by hierarchical power differentials and cultures of deference, this attribute is significantly amplified: staff may not voice concerns not because they have none, but because the leader's behavioural cues have established that honesty carries professional risk (Lee, Seo, and Squires 2024).

3.7. Attribute 3: Miscalibrated Confidence in Leadership Judgement

A third defining attribute is unwarranted certainty in the correctness of the leader's perceptions, decisions, and interpersonal assessments, independent of the actual accuracy of those judgements. Miscalibrated confidence may manifest as conviction that a performance evaluation is objective when it is influenced by in‐group favouritism, or as confidence that written communication has been understood when staff experience confusion or intimidation. The Dunning–Kruger effect provides one possible theoretical lens for understanding this pattern, suggesting that limitations in self‐assessment may coexist with high confidence in one's judgement (Dunning et al. 2003). Applied cautiously to nursing leadership, this perspective may help explain why some leaders remain confident in their relational effectiveness despite contradictory feedback from staff. Organizational structures that limit candid feedback may further sustain such miscalibration (Dunning et al. 2003; Tang et al. 2013).

3.8. Attribute 4: Relational‐Contextual Unawareness of Leadership Impact

A fourth defining attribute is the leader's unawareness of how contextual and relational factors—team hierarchy, workload distribution, emotional climate, and interpersonal dynamics within the unit—shape the way their behaviour and decisions are actually experienced by different staff members. This attribute extends beyond a single leader–staff dyad to encompass blind spots in how relational and organizational context filters the leader's impact: a leader may accurately understand their intended approach toward one nurse while remaining unaware of differential patterns across the wider team, of emotional cues that are apparent to colleagues but not to them, or of how positional power itself alters how staff interpret otherwise neutral behaviour (Hult et al. 2023; Rock 2008). Rather than describing a single emotional or interpersonal failing, this attribute captures the leaders' blindness to the situated, contextual nature of their own impact, which is why it is expressed clinically through several distinct manifestations, including emotional disconnection, inequitable practice, and inattention to staff silence (Table 2).

Table 2 presents these four defining attributes alongside six clinically observable manifestations—communication, fairness and equity, emotional, power, performance, and change‐related blind spots—illustrating how each manifestation expresses one or more of the core attributes in nursing practice. The key discriminator across all of the constructs in Table 3 is the combination of (a) a measurable self–other perception discrepancy and (b) the leader's lack of recognition of that discrepancy, rather than the presence of harmful behaviour, intent, or skill deficit alone.

TABLE 3.

Conceptual boundaries between leadership blind spots and related constructs.

Related construct	Core distinguishing feature	Relationship to leadership blind spots
Low general self‐awareness	Broad, trait‐level difficulty with self‐reflection across life domains, not specific to a leadership role	A leadership blind spot is the leadership‐specific, role‐bound expression of a self–other discrepancy; a leader can otherwise be self‐aware yet still hold a blind spot rooted in role‐specific feedback deprivation
Implicit bias	Unconscious attitudes toward social groups that influence judgement and behaviour	May contribute to specific manifestations (e.g., inequitable practice) but is a distinct mechanism operating on group‐level associations rather than on the leader's self‐perception
Destructive leadership	Leader behaviour that harms followers or the organization, whether or not the leader is aware of the harm	Blind spots concern the leader's unawareness of impact specifically; a destructively behaving leader may or may not also hold a blind spot
Abusive supervision	Sustained hostile verbal or non‐verbal supervisory behaviour toward subordinates	Abusive supervision concerns harmful supervisory behaviour, whereas a leadership blind spot specifically requires a self–other discrepancy that the leader insufficiently recognizes
Workplace Incivility	Low‐intensity disrespectful behaviour with ambiguous intent	Workplace incivility concerns low‐intensity disrespectful behaviour with ambiguous intent, whereas leadership blind spots concern an insufficiently recognized discrepancy between self‐perceived and externally experienced leadership impact
Leadership incompetence	A deficiency in technical, operational, or strategic leadership skills	Blind spots can coexist with high technical and operational competence; the deficit is perceptual and relational rather than necessarily skill‐based
Burnout	The leader's own self‐perceived exhaustion, cynicism, and reduced sense of efficacy	Burnout is typically self‐aware; the burned‐out leader perceives their own deterioration. Blind spots are defined precisely by the absence of this self‐perception
Leadership derailment	The downstream failure or removal event that can follow prolonged, uncorrected leadership problems from multiple causes	Derailment is a potential consequence of an unaddressed blind spot, not synonymous with the concept itself

3.8.1. Model Case and Other Cases

Constructing model, contrary, borderline, and related cases is an essential step in clarifying the boundaries and core attributes of a concept (Walker and Avant 2011). The following cases are illustrative composites reflecting documented patterns in nursing leadership research. While the individuals are fictional, the dynamics they represent are grounded in the existing literature on leadership self‐awareness, psychological safety, and nursing workforce experience (Hult et al. 2023; Lee, Seo, and Squires 2024; Cummings et al. 2021).

Nurse Manager Noura serves as head of a busy medical‐surgical unit in a tertiary care hospital. By institutional metrics, she appears to be an effective leader. Her unit consistently achieves patient‐satisfaction benchmarks; she receives favourable ratings from senior administration, and she regards herself as deeply committed to her team. Noura believes she communicates openly and has told staff on multiple occasions that her office door is always open (Attribute 1: self–other perceptual discrepancy—Noura's self‐assessment of open communication is not shared by staff, as the following events demonstrate).

However, a pattern invisible to Noura has been steadily developing. Staff who have attempted to raise concerns about unsafe staffing ratios on night shifts, a colleague's clinical deterioration, and a newly implemented documentation system that increases their administrative burden have received responses they experience as minimizing, such as ‘We are all doing the best we can,’ ‘This is a system‐wide challenge,’ and ‘Other units are managing just fine’ (Attribute 2: limited recognition and integration of corrective feedback—staff input is minimized rather than meaningfully considered).

Three senior nurses have resigned in the past four months, citing in their exit interviews a feeling of not being heard. Noura was not aware of these stated reasons (Attribute 4: relational‐contextual unawareness of leadership impact, expressed here as limited recognition of staff silence and departure as meaningful leadership signals). When asked by a nurse educator about unit morale, Noura responded with genuine confidence: ‘The team is doing well. We have a strong culture here’ (Attribute 3: miscalibrated confidence in leadership judgement).

This case illustrates all four defining attributes operating together: a self–other perceptual discrepancy sustained by limited recognition and integration of corrective feedback, accompanied by miscalibrated confidence in leadership judgement, and compounded by relational‐contextual unawareness that prevents staff silence and departure from being recognized as meaningful signals of leadership impact.

3.9. Contrary Case

Nurse Manager Malak leads a palliative care unit and carries significant institutional responsibility. What distinguishes Malak is her systematic effort to reduce the gap between her intentions and their impact on staff. She conducts quarterly anonymous climate surveys, discusses the findings openly with her team, and engages an external coach for multisource leadership assessment. When a staff nurse recently said, ‘I sometimes feel like my concerns are heard but not really acted on,’ Malak did not respond defensively. She listened, acknowledged the concern, and within the week introduced a standing agenda item titled ‘Staff Concerns in Action’ for unit meetings.

This contrary case demonstrates the substantial absence of the four defining attributes. Malak actively reduces the self–other perceptual discrepancy through structured feedback‐seeking (countering Attribute 1), recognizes and integrates corrective feedback into her leadership practice (countering Attribute 2), calibrates her confidence against external perspectives rather than relying solely on self‐assessment (countering Attribute 3), and remains attentive to relational and contextual signals, including subtle expressions of unmet staff needs (countering Attribute 4).

3.10. Borderline Case

Nurse Manager Omar is well regarded by senior leadership and genuinely cares about his staff. He responds with concern when individual nurses approach him with personal difficulties and is known for warmth in one‐to‐one interactions, reflecting adequate self–other perceptual accuracy at the individual level. However, during team meetings and institutional decision‐making, Omar consistently defers to the preferences of three high‐visibility nurses who have worked on the unit the longest. He remains unaware that the other twelve staff members have progressively stopped contributing ideas in group settings because they perceive that the established hierarchy determines whose voice receives attention (Attribute 4: relational‐contextual unawareness of leadership impact, present at the group level despite accurate individual‐level perception).

This borderline case demonstrates a partial leadership blind spot. Omar shows interpersonal warmth and individual‐level attunement, but he does not recognize how his group‐level leadership practices shape staff voice and participation. The case therefore illustrates that defining attributes of leadership blind spots may emerge selectively across leadership contexts rather than appearing uniformly across all relationships.

3.11. Related Case

Senior Charge Nurse Khaled is experiencing severe occupational burnout. He is visibly disengaged during team huddles, responds abruptly to staff questions, and has stopped participating in unit improvement initiatives. Khaled recognizes that he is struggling and has spoken openly with his nurse manager about feeling overwhelmed.

This related case differs fundamentally from a leadership blind spot in both its origin and defining mechanism. Khaled's reduced interpersonal effectiveness arises from burnout, but he recognizes the deterioration in his behaviour and its potential impact on others. The self–other perceptual discrepancy central to a leadership blind spot (Attribute 1) is therefore absent. Leadership blind spots, by contrast, involve insufficient recognition of a discrepancy between how leaders perceive their leadership and how their behaviour or impact is experienced by others.

This distinction demonstrates that impaired leadership behaviour does not necessarily constitute a leadership blind spot. The concept specifically requires an insufficiently recognized self–other perceptual discrepancy rather than leadership difficulty that is already recognized by the leader.

3.11.1. Antecedents of Leadership Blind Spots in Nursing

In Walker and Avant's framework, antecedents are the conditions, events, or contextual factors that must exist before a concept can occur (Walker and Avant 2011). For leadership blind spots in nursing, antecedents are organized across individual, contextual, and organizational levels.

3.12. Individual and Personal Antecedents

At the individual level, several personal characteristics predispose nurse leaders to develop blind spots. Limited external self‐awareness and weak self–other calibration—the capacity to accurately gauge how one's behaviour is perceived by others—represent central individual antecedents of leadership blind spots. Limited internal self‐awareness—the capacity to examine one's own motivations, patterns, and emotional responses with accuracy and honesty—functions as a supporting rather than a primary factor (Eurich 2017). Research by Eurich (2017) demonstrated that while most adults consider themselves self‐aware, only a fraction exhibit the external self‐awareness necessary for accurate leadership self‐assessment. Related to this, high task orientation without commensurate relational attunement narrows the leader's perceptual field, concentrating attention on operational outputs at the expense of the interpersonal environment.

Ego‐protective or authority‐protecting tendencies, though not constituting a clinical disorder, create strong psychological resistance to unflattering self‐relevant information (Yukl and Gardner 2020). Leaders with these tendencies experience critical feedback as threatening rather than useful, and their defensiveness signals to staff that honesty carries risk. A limited personal practice of critical reflection—whether through journaling, mentoring, peer dialogue, or structured self‐assessment—removes a mechanism through which perceptual gaps might otherwise be identified and corrected (Lee, Seo, and Macphee 2024). The absence of formal education in self‐awareness, interpersonal impact, and leadership psychology during nursing leadership preparation programs represents a formative antecedent: leaders cannot develop capacities they have not been taught to value or cultivate (Cummings et al. 2021).

3.13. Contextual and Organizational Antecedents

At the contextual level, hierarchical organizational cultures that normalize top‐down authority and discourage candid upward communication create structural conditions in which leadership blind spots flourish invisibly (Edmondson 2018). When staff members have learned through experience that raising concerns results in social or professional consequences, they adapt by withholding honest input—depriving leaders of the very feedback that could close perceptual gaps. High workload and relentless time pressure compound this dynamic: leaders operating under perpetual demand may have neither the cognitive bandwidth nor the protected time for the reflective practice necessary to interrogate their own conduct (Pihl‐Thingvad et al. 2025).

The absence of structured, anonymized feedback mechanisms—such as validated climate surveys, multisource (360‐degree) leadership assessments, or regular facilitated staff forums—means that the only corrective signals available to nurse leaders are the voluntary and often socially costly acts of individual nurses who choose to speak directly. In units where speaking directly to the manager has historically yielded minimization or retaliation, this avenue closes progressively. Additionally, the absence of coaching, mentoring, or peer leadership consultation structures leaves nurse managers without the external perspective that could challenge their self‐assessments (Cummings et al. 2021; Edmondson 2018).

At the organizational level, performance management systems that evaluate nurse leaders primarily on task‐based outcomes—budget adherence, patient‐satisfaction scores, staffing ratios—while ignoring relational climate and staff voice create incentive structures misaligned with blind spot prevention (Alhalal et al. 2024). When leaders are rewarded for operational metrics without accountability for the psychological health of their units, there is no institutional signal that motivates the uncomfortable work of self‐confrontation. Organizational cultures that treat negative staff feedback as a performance problem in the staff member rather than a diagnostic signal about the leader provide fertile ground for leadership blind spots to deepen and persist over time (Hult et al. 2023; Cummings et al. 2021).

3.14. Consequences of Leadership Blind Spots in Nursing

Consequences refer to the outcomes that occur as a result of the presence of a concept (Walker and Avant 2011). The consequences of leadership blind spots in nursing are multilevel, affecting nurse leaders themselves, nursing staff, patients, and healthcare organizations.

3.15. Consequences for Nurse Leaders

Nurse leaders with unexamined blind spots are themselves among the most significant casualties of the phenomenon. Over time, the behavioural patterns they do not perceive generate staff responses—disengagement, avoidance, formal complaints, turnover, and whistleblowing—that leaders experience as inexplicable or attributable to external factors. This attribution pattern reinforces defensiveness and intensifies the blind spot rather than resolving it. Leaders who reach a threshold of leadership derailment—removal, formal performance management, or irrecoverable loss of team trust—often report retrospectively that they had received no meaningful warning (Yukl and Gardner 2020; Conger 2024). The absence of perceived warning is what defines a blind spot. The result may include diminished decision quality, compromised crisis management, and the gradual disintegration of the professional relationships that effective nursing leadership requires (Yukl and Gardner 2020; Conger 2024).

3.16. Consequences for Nursing Staff

The proposed staff‐level consequences are supported indirectly by nursing evidence linking adverse leadership environments to elevated psychological unsafety—the conviction that speaking up involves personal risk (Edmondson 2018). This experience is associated with heightened emotional exhaustion, moral distress, and the constellation of behavioural adaptations collectively described as employee silence: withholding ideas, concerns, and safety‐relevant information from those in authority (Lee, Seo, and Squires 2024). The cumulative effect of prolonged exposure to a leadership environment perceived as dismissive, inequitable, or emotionally unavailable is well established in the nursing literature as a driver of burnout, disengagement, and turnover intention (Hult et al. 2023; Cummings et al. 2021).

Of particular significance is the relationship between leadership‐induced workplace incivility and nurses' work attitudes. Lee, Seo, and Macphee (2024) demonstrated that workplace incivility from leadership sources significantly increased burnout, which in turn correlated with heightened turnover intention, reduced job satisfaction, and diminished organizational commitment among large samples of hospital nurses. This consequence extends beyond individual suffering to threaten the broader professional culture of nursing and to impose measurable costs on healthcare organizations struggling with workforce sustainability.

3.17. Consequences for Patients

Leadership blind spots may have patient‐safety implications through their proposed relationship with staff silence, reduced speaking up, and safety‐event reporting. In units where staff silence is the dominant adaptive response to leadership, patient‐safety near‐misses and adverse events patient‐safety incidents, near misses, and adverse events are systematically under‐reported: staff who fear that raising a concern will be met with minimization or blame choose silence, and the institutional learning that depends on error reporting is suppressed (Edmondson 2018). Furthermore, the emotional depletion and burnout associated with exposure to leadership blind spots reduce the cognitive resources available to nurses for clinical vigilance, therapeutic communication, and patient advocacy—the very competencies most critical to safe and compassionate care (Hult et al. 2023; Lee, Seo, and Squires 2024).

3.18. Consequences for Healthcare Organizations

At the organizational level, the cumulative consequences of leadership blind spots manifest as elevated staff turnover and its associated recruitment and training costs, reduced capacity for innovation and quality improvement, and a weakened organizational culture characterized by distrust, reduced collaboration, and elevated grievance rates (Hult et al. 2023; Robinson‐Walker 2008; Lee, Seo, and Macphee 2024). In organizations where blind‐spot leaders are protected by their operational metrics while their relational harms remain unmeasured and unaddressed, institutional cultures develop that reward compliance over candour and silence over safety. These cultures are poorly positioned to respond to the rapidly evolving demands of contemporary healthcare.

Figure 3 presents the Leadership Blind Spot Pathway Model, illustrating the proposed pathway from individual, contextual, and organizational antecedents through the four defining attributes to multilevel consequences. The reinforcing feedback loop shows how reduced staff voice and under‐reporting of safety events may restrict corrective signals, allowing leadership blind spots to persist or deepen over time.

The model illustrates how individual, contextual, and organizational antecedents may contribute to the four defining attributes of leadership blind spots and their manifestations, with proposed pathways to nurse/staff, organizational, and patient outcomes. Reduced staff voice and under‐reporting of safety events may restrict corrective signals and reinforce leader unawareness. Multisource feedback, reflective leadership practice, anonymous climate surveys, coaching and mentoring, and psychological safety training represent proposed intervention points. The model was developed from the present concept analysis and requires empirical validation.

3.19. Empirical Referents of Leadership Blind Spots in Nursing

Empirical referents are the observable, measurable phenomena that demonstrate the presence of a concept in real‐world practice (Walker and Avant 2011). For leadership blind spots in nursing, these referents must capture the perception gap that constitutes the concept's core, translating an inherently subjective and dyadic phenomenon into observable and quantifiable indicators, organized around the four core defining attributes.

The most direct empirical referent is the discrepancy score derived from multisource (360‐degree) leadership assessment: the measured difference between a nurse leader's self‐ratings on behavioural competency scales and ratings provided by staff on the same items (Cummings et al. 2021). Large positive discrepancy scores—in which leaders rate themselves substantially higher than staff on dimensions such as communication clarity, fairness, emotional availability, and responsiveness to feedback—provide a quantitative indicator of the perceptual gap that defines leadership blind spots. Current multisource instruments used in nursing leadership development, including the Multifactor Leadership Questionnaire (MLQ) and Leadership Practices Inventory (LPI), offer partial operationalization of this referent, though they were not designed specifically to capture the blind spot construct (Tang et al. 2013).

Staff‐reported psychological safety, measured through validated instruments such as Edmondson's Team Psychological Safety Scale (Edmondson 2018), provides an additional empirical referent. Units with low psychological safety scores in the context of leaders who rate themselves as open and approachable demonstrate a measurable manifestation of the leadership blind spot phenomenon. Similarly, staff‐reported measures of perceived fairness, voice climate, and leader responsiveness—available through instruments such as the Nursing Work Index, the Practice Environment Scale, the Organizational Justice Scale, and Nembhard and Edmondson's (2006) leader inclusiveness measures—provide complementary referents that capture different facets of the blind spot experience.

Observable behavioural indicators at the unit level constitute a third category of empirical referents. These include staff turnover rates, absenteeism patterns, incident‐reporting rates relative to estimated event frequency, participation rates in quality‐improvement initiatives, and the frequency and content of staff grievances. While none of these indicators are specific to leadership blind spots in isolation, their co‐occurrence with high leader self‐rated effectiveness constitutes a pattern recognizable as the empirical fingerprint of the concept. Lee, Seo, and Squires (2024) demonstrated through structural equation modelling that nurse voice, silence, and burnout are meaningfully linked constructs that reflect the quality of the leadership environment, providing a plausible pathway for empirical referent assessment.

Currently, no validated instrument specifically designed to measure nursing leadership blind spots exists. The development of such an instrument—a Nursing Leadership Blind Spot Scale—grounded in the four defining attributes identified in this concept analysis and incorporating both self‐report and staff‐report components, constitutes a priority for future research. Among the referents described above, the matched leader–staff self–other discrepancy score represents the most conceptually proximal empirical referent since it directly operationalizes the perceptual gap that defines the concept. Psychological safety, staff voice, turnover, incident reporting, and grievance patterns should be considered complementary contextual indicators, as they may arise from multiple organizational causes beyond leadership blind spots specifically. Table 4 presents attribute‐based empirical referents with observable indicators, potential measurement tools, and example measurement statements for each of the four defining attributes.

TABLE 4.

Attribute‐based empirical referents of leadership blind spots in nursing.

Defining attribute	Observable indicators	Potential measurement tools	Example measurement statement
1. Self–other perceptual discrepancy	Large self–other rating gap Attribution of staff concerns to external causes Absence of feedback‐seeking behaviour	360° leadership assessment (MLQ, LPI) Self–other agreement discrepancy score Structured reflection logs	‘I accurately understand how my leadership behaviour affects the nurses I supervise’
2. Limited recognition and integration of corrective feedback	Dismissive responses to staff concerns Absence of behavioural change after feedback Avoidance of survey/climate data	Staff‐reported feedback‐responsiveness scales Structured feedback‐uptake logs Post‐survey action‐plan audits	‘When staff raise concerns about my leadership, I genuinely listen and make visible changes in response’
3. Miscalibrated confidence in leadership judgement	Overconfidence in decisions with poor outcomes Minimal staff consultation Leader self‐ratings substantially exceed peer ratings	Calibration measures Peer‐review records Self–other calibration measures	‘I am confident that my assessment of team dynamics accurately matches how nursing staff experience them’
4. Relational‐contextual unawareness of leadership impact	Differential task/opportunity assignment patterns Low staff‐reported emotional‐support scores Low incident‐reporting and quality‐improvement participation; elevated absenteeism; grievance rates linked to recognition or discipline	Organizational Justice Scale; Practice Environment Scale–Nursing Work Index fairness subscale Emotional‐support and compassionate‐leadership indicators Edmondson's Team Psychological Safety Scale; Voice Climate Scale; incident‐tracking data	‘I actively notice and respond when nursing staff become unusually quiet, withdrawn, unequally treated, or emotionally distant from the team’

3.20. Concept Analysis Summary

Table 5 provides a comprehensive summary of the concept analysis findings related to leadership blind spots in nursing. The table synthesizes the proposed conceptual definition, defining attributes, antecedents, consequences, empirical referents, conceptual boundaries, practical implications, and future research directions. The findings suggest that leadership blind spots may be insufficiently recognized perceptual and relational gaps shaped by individual, contextual, and organizational factors that influence leadership effectiveness and staff experiences; the analysis further highlights the multidimensional consequences of blind spots on nurse leaders, staff well‐being, patient safety, and organizational functioning, while emphasizing the need for empirical validation, nursing‐specific assessment tools, and reflective leadership development strategies.

TABLE 5.

Concept analysis summary: leadership blind spots in nursing.

Category	Findings
Definition	A proposed, theoretically grounded, recurring and insufficiently recognized discrepancy between how nurse leaders perceive their own leadership behaviour and how that behaviour is experienced by staff in relation to trust, voice, fairness, psychological safety, and work engagement; perpetuated by cognitive biases, organizational culture, and the absence of structured corrective feedback
Attributes	(1) Self–other perceptual discrepancy; (2) Limited recognition and integration of corrective feedback; (3) Miscalibrated confidence in leadership judgement; (4) Relational‐contextual unawareness of leadership impact — expressed clinically through six manifestations: communication, fairness/equity, emotional, power, performance, and change‐related blind spots (Table 2)
Antecedents	Individual: low external self‐awareness, high task orientation, ego‐protective or authority‐protecting tendencies, limited reflective practice, inadequate leadership self‐assessment education Contextual: hierarchical culture, high power distance, absent anonymized feedback, high workload Organizational: absent multisource (360°) systems, no coaching or mentoring, metric‐only performance management
Consequences	Leaders: professional isolation, derailment, diminished decision quality Staff: reduced psychological safety, silence, burnout, turnover intention, moral distress Patients: under‐reporting of safety events, reduced care quality Organizations: toxic culture, elevated turnover, weakened innovation, organizational quality risk
Empirical Referents	Self–other discrepancy scores (multisource assessment); psychological safety scale scores; organizational justice and voice‐climate measures; turnover and incident‐reporting rates; QI participation; grievance patterns. See Table 4 for attribute‐specific referents
Conceptual Boundaries	Distinguished from low general self‐awareness, implicit bias, destructive leadership, abusive supervision, workplace incivility, leadership incompetence, burnout, and leadership derailment by the combined presence of a measurable self–other discrepancy and the leader's lack of recognition of it (Table 3)
Challenges	No validated nursing‐specific instrument currently exists. Blind spots are self‐concealing and resist standard survey methods. Organizational cultures may suppress the staff‐reported data needed to detect them
Practical Implications (proposed, pending evaluation)	Multisource (360°) feedback, reflective leadership education, anonymous staff climate surveys, organizational coaching, psychological safety training, and inclusive leadership programs
Future Research	Empirical testing of the four proposed attributes; development and validation of a Nursing Leadership Blind Spot Scale; longitudinal and cross‐cultural studies; intervention trials of multisource feedback and reflective coaching

4. Discussion

This concept analysis proposes leadership blind spots as a potentially distinct and multidimensional phenomenon in nursing that has not yet been formally conceptualized or empirically validated as a nursing‐specific construct. Drawing on convergent findings from organizational psychology, nursing leadership research, and the psychological safety literature, we propose the following definition: a nursing leadership blind spot is a recurring and insufficiently recognized discrepancy between how a nurse leader perceives their own leadership behaviour and how that behaviour is actually experienced by staff in relation to trust, voice, fairness, psychological safety, and professional engagement—a discrepancy perpetuated by cognitive biases, hierarchical culture, and the absence of structured corrective feedback. This definition is offered as a theoretically grounded proposition rather than an empirically established fact, and it requires testing across nursing populations and healthcare contexts before its boundaries can be considered settled. We use ‘insufficiently recognized’ rather than ‘unconscious’ deliberately: the latter implies access to unconscious mental processes that this analysis does not claim and that would be difficult to operationalize empirically, whereas a recognition gap can be assessed directly through paired leader–staff measurement.

This definition aligns with and extends foundational frameworks (Table 1). From the Johari Window (Luft and Ingham 1955), it draws the distinction between what the leader perceives of their own behaviour and what others perceive—treating staff experience as an essential external perspective on leadership impact, rather than as objective ground truth independent of context. Staff perceptions, like leader self‐perceptions, are shaped by interpersonal history, role position, and organizational climate; the value of staff‐reported data lies not in its infallibility but in its independence from the leader's own self‐referential frame, which is precisely the vantage point a blind spot obscures.

From Eurich's empirical research on self‐awareness (Eurich 2017), the definition incorporates the evidence‐based insight that external self‐awareness is both comparatively rare and consequential, and that its absence is self‐concealing in ways that require active organizational investment to overcome. From Edmondson's work on psychological safety (Edmondson 2018), it draws the recognition that leadership blind spots are not merely an interpersonal phenomenon but a systems‐level concern: when leaders cannot perceive the fear they generate, the information systems that healthcare organizations depend upon—error reporting, staff feedback, quality‐improvement participation—become compromised.

The four defining attributes identified in this analysis constitute the proposed behavioural and perceptual signature of nursing leadership blind spots, offered to help distinguish the concept from adjacent phenomena rather than to claim final conceptual closure. As detailed in Table 3, leadership blind spots differ from low general self‐awareness in their leadership‐specific, role‐bound character; from implicit bias in operating on self‐perception rather than group‐level attitudes; from destructive leadership and abusive supervision, which concern harmful behaviour regardless of the leader's awareness of it, whereas a blind spot specifically requires the leader's insufficient recognition of the self–other discrepancy; from workplace incivility, which concerns low‐intensity disrespectful behaviour with ambiguous intent, whereas leadership blind spots specifically concern an insufficiently recognized discrepancy between leaders' self‐perceptions and externally experienced leadership impact; from leadership incompetence in that they can coexist with high technical and operational skill; and from burnout in that the burned‐out leader is typically self‐aware of their own deterioration, whereas the blind‐spot leader is not. The key discriminator across all of these comparisons is the combination of a measurable self–other perception discrepancy and the leader's lack of recognition of that discrepancy, rather than the presence of harmful behaviour, intent, or skill deficit in isolation.

The six manifestation types presented in Table 2—communication, fairness, emotional, power, performance, and change‐related blind spots—provide a clinically grounded taxonomy, linked explicitly to the four core attributes, that can serve multiple functions. For nurse educators, it offers a vocabulary for teaching leadership self‐examination that is more specific and actionable than the general prescription to ‘develop self‐awareness.’ For nurse managers, it provides a structured framework for self‐reflection: in which of these domains is my self‐perception most at risk of diverging from my staff's experience? For healthcare organizations, it constitutes a set of observable leadership behaviours against which formal assessment instruments can be designed and validated (Tang et al. 2013).

The antecedents identified in this analysis reinforce the view that leadership blind spots are not solely a matter of individual character but are substantially shaped by the organizational conditions in which leaders operate. Hierarchical cultures, absent feedback structures, and performance management systems that reward operational metrics while ignoring relational climate create the environmental substrate in which blind spots develop and persist. This finding carries significant implications for healthcare organizations: addressing leadership blind spots is not merely a matter of individual coaching but requires institutional redesign of the feedback architecture surrounding nurse manager roles (Abd‐El Aliem and Abou Hashish 2021; Abou Hashish et al. 2023).

The consequences of leadership blind spots span all levels of the healthcare system and align closely with the most pressing challenges confronting nursing today. The erosion of psychological safety, the amplification of staff silence, the intensification of burnout, and the suppression of safety‐event reporting are each independently identified as major threats to nursing workforce sustainability and patient safety (Hult et al. 2023; Lee, Seo, and Squires 2024; Edmondson 2018). The proposition that leadership blind spots constitute a meaningful and addressable contributor to these outcomes requires empirical testing but, if supported, would position blind‐spot recognition and reduction as a high‐leverage intervention point for healthcare systems seeking to improve both staff well‐being and care quality.

4.1. Relational Pathway Among Antecedents, Attributes, Consequences, and Empirical Referents

The four defining attributes do not operate in isolation from the antecedents that give rise to them or the consequences that follow. Individual antecedents such as low external self‐awareness and ego‐protective or authority‐protecting tendencies predispose leaders toward self–other perceptual discrepancy (Attribute 1) and miscalibrated confidence (Attribute 3) because both arise from cognitive mechanisms that resist unflattering self‐relevant information. Contextual and organizational antecedents—hierarchical culture, absent anonymized feedback systems, high workload, and metric‐only performance management—act primarily on limited recognition and integration of corrective feedback (Attribute 2) by removing or discouraging the channels through which a discrepancy could otherwise be identified and closed. Relational‐contextual unawareness (Attribute 4) sits at the intersection of both antecedent categories: it is shaped by individual attentional limits but is also produced or amplified by organizational conditions that leave relational and emotional information invisible to leaders whose attention is directed toward operational metrics.

Once present, the four attributes generate consequences that are not simply downstream outcomes but function as inputs that reinforce the originating attributes. Staff silence, reduced psychological safety, and elevated turnover intention (consequences for staff) deprive the leader of the corrective feedback that could otherwise reduce Attribute 2; under‐reporting of safety events (a consequence for patients) similarly removes an external signal that might otherwise inform the leader's self‐assessment and reduce Attribute 1. This reinforcing structure—illustrated by the feedback loop in Figure 3—offers one explanation for why leadership blind spots may persist and deepen rather than self‐correct over time, and it identifies the empirical referents in Table 4 as candidate measurement points at each stage of this pathway rather than as isolated indicators of a static trait.

4.2. The Intention–Impact Paradox

A central feature of leadership blind spots is the possible coexistence of positive leadership intention and negatively experienced impact. Nurse leaders may genuinely intend to communicate efficiently, support staff, distribute opportunities fairly, or implement necessary organizational change while remaining unaware that these behaviours are experienced differently by members of the team. Positive intent therefore does not exclude the possibility of a leadership blind spot, just as negative staff experience alone does not establish one. The concept resides in the unrecognized discrepancy between intended or self‐perceived leadership and externally experienced impact.

This distinction has implications for how healthcare organizations respond to leadership concerns. Where problematic behaviour is deliberate and recognized, accountability‐focused responses may be appropriate. Where a recurrent self–other discrepancy remains outside the leader's awareness, developmental approaches involving feedback, reflection, and coaching may offer a more conceptually appropriate starting point. This distinction does not minimize staff experiences or leadership accountability; rather, it recognizes that identifying the mechanism underlying problematic leadership behaviour may inform the type of organizational response required.

4.3. Cultural and Organizational Context

Leadership blind spots should also be interpreted within the cultural and organizational contexts in which leadership relationships occur. Norms concerning authority, hierarchy, interpersonal respect, disagreement, and upward communication vary across organizations and societies and may influence how readily staff provide corrective feedback to leaders (Lee and Lee 2024; Joseph and Shetty 2022). Cultural dimensions such as power distance may therefore offer one contextual lens for examining leadership blind spots, but they should not be treated as fixed characteristics of individual countries, organizations, or healthcare professionals.

In settings where hierarchical authority is strongly emphasized, staff may be less likely to openly challenge senior colleagues or communicate negative feedback upward (Lee and Lee 2024). However, substantial variation may exist within the same national context according to organizational culture, professional group, leadership approach, generation, team climate, and individual experience. Silence should therefore not automatically be interpreted as cultural acceptance or agreement. It may reflect respect for authority, interpersonal caution, perceived lack of psychological safety, previous experience of speaking up, or other contextual influences (Edmondson 2018; Lee and Lee 2024).

Cross‐cultural research is needed to determine whether the antecedents, manifestations, and consequences proposed in this analysis operate similarly across healthcare systems. Such studies should examine whether cultural and organizational conditions modify the relationship between self–other leadership discrepancies, staff voice, corrective feedback, and persistence of blind spots, rather than assuming uniform effects based on country‐level cultural classifications.

4.4. Digital Leadership Blind Spots

Digital transformation may create additional contexts in which leadership blind spots warrant investigation. Nursing leadership increasingly occurs through electronic communication, virtual meetings, digital dashboards, workforce‐management systems, and AI‐supported decision environments (Abou Hashish 2025; Abou Hashish and Alnajjar 2025; Abou Hashish et al. 2025). These technologies may increase access to operational information while simultaneously reducing exposure to informal interpersonal cues through which staff concern, hesitation, emotional strain, or disagreement may become visible.

A potential digital leadership blind spot may therefore arise when leaders interpret digitally available performance indicators as an adequate representation of team functioning while relational experiences remain less visible. Email and virtual communication may also limit access to some nonverbal and contextual cues available during face‐to‐face interaction. These propositions require empirical investigation. Future research should examine whether technology‐mediated leadership changes the detection, expression, or correction of self–other leadership perception discrepancies, rather than assuming that digitalization inherently increases blind spots.

4.4.1. Practical Implications for Nursing and Healthcare Organizations

The findings of this concept analysis generate concrete and actionable implications for nursing practice, leadership development, healthcare organization, and policy, offered as proposals for evaluation rather than as established requirements.

4.5. For Nursing Practice and Nurse Leaders

Nurse leaders should be supported and encouraged to engage in ongoing reflective leadership practice—structured self‐examination of the gap between their intentions and their behavioural impact on staff. This may take the form of reflective journaling guided by the manifestation types identified in this analysis, regular one‐to‐one dialogue with a coach or mentor who can offer an honest external perspective, and participation in facilitated peer leadership groups where candid cross‐evaluation is normalized (Eurich 2017; Cummings et al. 2021). Nurse leaders should actively cultivate the conditions in which staff voice is possible: demonstrating visible responsiveness to critical feedback, publicly narrating the changes they make in response to staff input, modelling the vulnerability necessary to close the blind quadrant of the Johari Window (Luft and Ingham 1955), and fostering the moral courage that Huang et al. (2025) identify as essential for nurse leaders who wish to build ethically honest team environments.

4.6. For Nursing Education and Leadership Development

Leadership preparation in nursing could extend beyond teaching leadership styles and competencies to include external self‐awareness, self–other perception discrepancies, feedback literacy, reflective practice, and recognition of staff silence as potentially meaningful relational information. Leadership‐development activities could use simulation, multisource case analysis, reflective journaling, facilitated peer feedback, and scenario‐based exercises in which leaders compare intended communication with how the same behaviour may be experienced by staff.

Graduate nursing administration and leadership programs may also use the concept to examine the distinction between intention and impact. Developing the capacity to ask ‘How might others experience this behaviour differently from how I intend it?’ may provide a practical reflective question for emerging nurse leaders. The effectiveness of such educational strategies should be examined through longitudinal studies rather than assumed from conceptual plausibility alone.

4.7. For Healthcare Organizations

The concept of leadership blind spots has potential implications for nursing leadership development because conventional self‐assessment alone may be insufficient for identifying a phenomenon defined partly by limited awareness of one's external impact. Leadership‐development programs could therefore consider incorporating multisource feedback, guided reflective practice, coaching, and structured opportunities for staff voice. These approaches should be evaluated empirically before being recommended as universal or mandatory interventions.

Multisource feedback may be particularly relevant because it permits comparison between leader self‐perceptions and external perspectives across matched leadership domains. Its value, however, depends on the quality of the feedback process. Feedback that is punitive, poorly contextualized, or disconnected from developmental support may encourage defensiveness rather than reflection. Organizations considering multisource assessment should therefore pair feedback with interpretation, coaching, opportunities for clarification, and follow‐up assessment.

Psychological safety is equally relevant because feedback systems have limited value when staff do not feel able to communicate candidly. Nurse executives and healthcare organizations could examine whether formal and informal channels permit nurses to raise concerns, challenge assumptions, and discuss leadership experiences without fear of interpersonal or professional consequences. Anonymous climate assessment may supplement direct feedback where hierarchical relationships make upward communication difficult.

4.8. For Policy and Quality Standards

At the organizational level, leadership evaluation systems could be examined for the extent to which they capture relational as well as operational dimensions of leadership performance. Reliance solely on productivity, staffing, financial, or quality indicators may provide an incomplete picture of how leadership is experienced by staff. Organizations may therefore consider integrating staff climate data, multisource feedback, voice indicators, and developmental coaching into leadership‐review processes where appropriate.

The potential value of incorporating leadership self‐awareness and feedback mechanisms into organizational quality or leadership standards warrants future evaluation. Evidence is currently insufficient to recommend leadership blind‐spot assessment as a formal accreditation requirement. Empirical studies should first determine whether proposed indicators demonstrate reliability, validity, feasibility, and meaningful relationships with nursing workforce and patient‐care outcomes. Development and validation of a Nursing Leadership Blind Spot Scale represents an important research priority that could establish whether the proposed construct provides meaningful information for leadership development, workforce sustainability, and patient safety.

5. Strengths and Limitations

This concept analysis integrates nursing leadership literature with relevant perspectives from organizational psychology, self‐awareness research, psychological safety, staff voice, and leadership science to clarify an underdeveloped phenomenon. Application of Walker and Avant's framework enabled systematic examination of concept uses, defining attributes, cases, antecedents, consequences, and empirical referents. The analysis also proposes conceptual boundaries and operational indicators that can be tested in future nursing research.

Several limitations should be acknowledged. First, leadership blind spots have not yet been empirically validated as a nursing‐specific construct, and the proposed attributes and pathway model therefore remain conceptual propositions requiring testing. Second, the supporting literature includes evidence derived from adjacent constructs rather than studies directly measuring nursing leadership blind spots; associations reported for psychological safety, silence, burnout, turnover, or patient safety should consequently not be interpreted as demonstrated effects of the proposed construct. Third, the literature search was designed to support concept analysis rather than to constitute a systematic review of intervention effects or prevalence. Fourth, source screening and conceptual synthesis were conducted by a single author, which may increase interpretive subjectivity. Finally, restriction to English‐language sources and the multidisciplinary nature of the concept may have resulted in relevant perspectives being missed, particularly from healthcare systems where power distance and hierarchical culture are most pronounced.

6. Recommendations for Future Research

Future research should first test whether leadership blind spots function empirically as a construct distinguishable from external self‐awareness, implicit bias, destructive leadership, incivility, leadership incompetence, burnout, and derailment (Table 3). Qualitative studies involving both nurse leaders and staff could examine how self–other leadership discrepancies are experienced and interpreted, and whether the four defining attributes identified in this analysis adequately capture the phenomenon.

Measurement research should prioritize multisource approaches because exclusive reliance on leader self‐report presents an inherent limitation when the phenomenon involves information that may remain outside the leader's awareness. Paired leader–staff ratings could quantify discrepancies across communication, fairness, emotional responsiveness, power, recognition, and change leadership. Subsequent scale‐development studies should evaluate content validity, factor structure, reliability, convergent and discriminant validity, and measurement invariance across leadership levels and cultural contexts.

Longitudinal studies are needed to determine whether self–other discrepancies remain stable, increase, or diminish over time, and whether psychological safety, staff voice, coaching, or organizational feedback systems modify these trajectories. Intervention studies could evaluate whether structured multisource feedback combined with reflective coaching reduces discrepancies between leader self‐assessment and staff experience.

Cross‐cultural studies should examine organizational and cultural moderators without assuming that national cultural categories determine individual behaviour. Digital leadership also warrants investigation, particularly whether virtual communication, digital performance monitoring, and AI‐supported management alter leaders' access to relational information or change the mechanisms through which corrective feedback reaches them.

Finally, future research should test the propositions generated by this analysis, including whether staff silence mediates the persistence of leader unawareness and whether psychological safety moderates the relationship between initial self–other discrepancy and subsequent correction of the blind spot.

7. Conclusion

Leadership blind spots are proposed as a potentially important metaperceptual phenomenon in nursing leadership, characterized by a recurring and insufficiently recognized discrepancy between leaders' self‐perceptions and how their leadership behaviour and impact are experienced by others. This concept analysis identifies four defining attributes: self–other perceptual discrepancy, limited recognition and integration of corrective feedback, miscalibrated confidence in leadership judgement, and relational‐contextual unawareness of leadership impact.

The analysis further proposes that leadership blind spots may emerge through the interaction of perceptual miscalibration and feedback deprivation and may manifest across communication, fairness, emotional responsiveness, power, performance, and change leadership. Staff silence occupies a central position in the proposed pathway because reduced upward voice may both reflect the relational impact of leadership and restrict the corrective information available to leaders, thereby allowing blind spots to persist.

Leadership blind spots should not be considered synonymous with destructive leadership, incompetence, burnout, or intentional misconduct. Their distinguishing feature is insufficient recognition of a recurring self–other leadership discrepancy. The concept therefore provides a potentially distinct and operationalizable framework for nursing leadership research, although empirical validation is required before its measurement, consequences, and interventions can be established. Future research should test the proposed attributes and pathway, develop and validate appropriate measures, and examine whether multisource feedback, psychological safety, reflective practice, inclusive leadership, and coaching can reduce self–other leadership discrepancies and improve nursing workforce and patient‐care outcomes.

Author Contributions

Ebtsam Aly Abou Hashish: conceptualization, writing – original draft, methodology, visualization, writing – review and editing, software, project administration, supervision.

Funding

The author has nothing to report.

Disclosure

Article type: Concept Analysis. This manuscript is not a systematic review, observational study, qualitative study, or clinical trial.

Reporting guideline: To enhance transparency, this revision strengthens reporting of the supporting literature search, including database‐specific search strategies, applied limits, eligibility criteria, screening procedures, source selection, and a flow diagram informed by, though not claiming full conformity with, PRISMA reporting principles (Figure 2 and File S1).

Ethics Statement

Ethics approval and informed consent were not applicable because this concept analysis was based exclusively on previously published literature and did not involve human participants, identifiable personal data, or primary data collection.

Conflicts of Interest

The author declares no conflicts of interest.

Supporting information

File S1: Electronic search strategies.

Data Availability Statement

No new datasets were generated or analyzed in this concept analysis. All sources informing the analysis are publicly available through the publications cited in the manuscript. The literature search strategy is provided in File S1.