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• To recognise the importance of effective leadership during highly challenging periods, such as the coronavirus disease 2019 (COVID-19) pandemic
• To understand the advantages and disadvantages of using the transactional, transformational and laissez-faire leadership styles in the context of the COVID-19 pandemic
• To be aware of the potential benefits of compassionate leadership during the COVID-19 pandemic
Leadership is central to effective nursing practice and is considered to be particularly important during crises such as the coronavirus disease 2019 (COVID-19) pandemic. This article examines several leadership styles that are commonly used in healthcare – namely the transactional, transformational and laissez-faire leadership styles – and considers their advantages and disadvantages in the context of the COVID-19 pandemic. It also explains the potential benefits of compassionate leadership in supporting the nursing workforce during this highly challenging and stressful period.
Nursing Standard. doi: 10.7748/ns.2021.e11601
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
CorrespondenceAnneharrington2@virginmedia.com
Conflict of interestNone declared
Harrington A (2021) Understanding effective nurse leadership styles during the COVID-19 pandemic. Nursing Standard. doi: 10.7748/ns.2021.e11601
Published online: 22 April 2021
Leadership is central to effective nursing practice. It has an essential role in: providing a vision for optimal practice; inspiring, motivating and supporting staff; considering how practice can be improved; encouraging professional growth and development; and ensuring the interests and concerns of the nursing profession are addressed (Daly et al 2020).
The coronavirus disease 2019 (COVID-19) pandemic has resulted in numerous workforce challenges, including staff shortages; increasing demand for services; sickness and absence because of quarantine measures; a changing workforce, including returners and nursing students who have opted to become members of the workforce; a shortage of equipment; and staff who are tired and anxious (James and Bennett 2020). However, it has also provided an opportunity for nurses to reflect on the qualities of effective leadership and identify potential areas for improvement.
Daly et al (2020) suggested that while there is much to celebrate in nurse leadership, the pandemic has demonstrated there are several areas that could be strengthened to better serve patients and the broader nursing workforce. According to these authors, while nursing has a central role in managing COVID-19, the profession is often discussed as a commodity and a transactional element of a supply chain. For example, Daly et al (2020) cited the decision to bring retired nurses back into practice to support the workforce, but commented that there was little discussion regarding how these retired nurses would contribute or the education and support they would require. They also asserted that the COVID-19 pandemic has demonstrated how nurses are not fully considered in policy development or present at the ‘decision-making table’ as equals.
The pandemic has led to physical and emotional exhaustion among the nursing profession in the UK and worldwide. Howard Catton, chief executive of the International Council of Nurses (ICN), identified reports from more than 130 of the ICN’s national nursing associations worldwide that suggested a large number of nurses may leave the profession sooner than planned because of the stresses they are experiencing (Catton 2021). According to Catton (2021), even if only one in ten nurses were to leave the profession, a new global nurse deficit of 13 million could occur.
Leadership, and how nurses choose to lead, is vital to maintain morale within the profession and to support staff. Pishgooie et al (2019) found that certain leadership styles can reduce the job stress experienced by nurses and their intention to leave the profession. They also suggested that leaders should attempt to raise confidence within their team, and ensure they feel respected and cared for. This is particularly crucial during periods of high stress and significant challenges, such as the COVID-19 pandemic. Therefore, it is important to recognise which leadership styles may be the most effective in optimising patient care and ensuring staff feel supported during this period.
This article explores several leadership styles that are commonly used in healthcare and discusses their use in the context of the COVID-19 pandemic. It also explores the potential role of compassionate leadership in supporting the nursing workforce at this highly challenging and stressful time.
• The coronavirus disease 2019 (COVID-19) pandemic has provided an opportunity for nurses to reflect on the qualities of effective leadership and identify potential areas for improvement
• Leadership, and how nurses choose to lead, is vital to maintain morale within the profession and to support staff
• It is important that nurses understand the benefits and limitations of the transactional, transformational, and laissez-faire leadership styles in different situations
• Compassionate leadership may be beneficial to ensure staff feel supported, valued and motivated during the COVID-19 pandemic
When discussing leadership, it is important to distinguish between the roles of leaders and managers, because nursing teams will encounter both roles in their daily practice. Lucas (2019) asserted that leadership and management are separate entities, but that these terms are often used interchangeably.
Tyler (2007) suggested that the aim of management is to control and coordinate the activities of staff within an organisation, and to ensure they are working towards the achievement of the organisation’s goals. In nursing, managers will have a position within the hierarchy of a healthcare organisation, so they will have subordinates, or people who report directly to them. In contrast, nurse leaders will not necessarily have a position within the hierarchy of a healthcare organisation, but they need to have a vision for how effective services can be developed and how optimal patient care can be provided (Lucas 2019).
All managers within healthcare organisations should be able to communicate, inspire and coach their teams. Staff rely on their managers for direction, guidance and support. However, some managers may not have the competencies required to be an effective leader. Bennis (1984) suggested that leaders should possess four competencies:
• Management of attention – drawing others to them by communicating a vision, a dream or set of clear intentions.
• Management of meaning – making their vision apparent to others by communicating it and conveying its rationale.
• Management of trust – demonstrating reliability, dependability and constancy to other members of the team.
• Management of self – having an awareness of their personal skills and deploying them effectively. This needs to be aligned with a recognition of their limitations.
The main competencies and functions of a manager differ to those of a leader. Hannigan (1995) detailed a set of activities for managers to focus on, which remain relevant today. These core functions of a manager are outlined in Box 1.
Planning
• Sets goals to be achieved and outlines the operational plans
• Draws and submits budgeting costs
• Allocates and delegates resources
Organising
• Carefully develops and establishes a structure to accomplish the desired plans
• Communicates the vision and plan with the team, and keeps reinforcing it
• Engages and develops staff and assigns responsibilities by finding the ‘best fit’ between people and tasks
• Outlines and develops robust policies, procedures and systems to monitor progress
Coordinating activities
While a leader could also fulfil the functions outlined in Box 1, they also need to have the ability to influence others and develop visions for change. Bennis and Nanus (2003) observed that ‘managers are people who do things right and leaders are people who do the right thing’; that is, managers tend to be inflexible, whereas leaders follow their intuition and aim to understand their team members to deliver optimal outcomes, such as person-centred care.
Various frameworks have detailed the qualities and behaviours associated with leadership roles. For example, the Healthcare Leadership Model (NHS Leadership Academy 2013) outlines nine dimensions of leadership behaviour: inspiring shared purpose; leading with care; evaluating information; connecting our service; sharing the vision; engaging the team; holding to account; developing capability; and influencing for results. Similarly, the Scottish Leadership Qualities Framework (NHS Scotland 2014) provides a summary of leadership qualities, outlined in Table 1.
(Adapted from NHS Scotland 2014)
These frameworks suggest that, with training and education, nurses can enhance their leadership behaviours and develop qualities that enable them to be effective leaders. Furthermore, in addition to enhancing the development of individual leaders, it is important to enhance collective leadership capability within healthcare teams and organisations (NHS Scotland 2014).While leaders serve a different organisational purpose than managers, both of these roles are important during the COVID-19 pandemic. For example, management is essential to plan, organise and coordinate care activities, while leadership is required to develop an environment for providing effective patient care and to support staff.
There has been extensive research on a wide variety of leadership theories, styles and models. This has ranged from early 20th century trait theories, which focused on leaders’ qualities and proposed that these qualities are inherent within individuals and cannot be taught, to contingency leadership models such as that by Fiedler (1967), which suggested that the interaction between the leadership style used and the situation predicts the effectiveness of a leader. Avolio and Bass (2002) developed the Full Range of Leadership Model, which outlined three main leadership styles: transactional, transformational, and laissez-faire. These leadership styles all have a role in nursing, but it is important that nurses understand the benefits and limitations of each style in different situations, particularly in the context of the COVID-19 pandemic.
Transactional leadership is task-focused, involving short-term goals and leaders influencing their teams with rewards and incentives (Burns 1978, Bass 1985, Richards 2020). Transactional leaders monitor their followers and take corrective action to promote effective working and task completion, and they provide tangible benefits or rewards for optimal performance. In effect, a transaction takes place between the leader and their followers. If an individual or the team performs as the leader requires and completes the necessary tasks, they will receive a reward, for example praise or positive feedback. However, the leader will impose sanctions for suboptimal performance or failing to meet the standards required.
One element of transactional leadership is ‘management by exception’ (Richards 2020), whereby a leader intervenes only when necessary, but establishes sanctions for failing to meet the required standards. Management by exception can be either active or passive. In active management by exception, the leader seeks out errors and enforces rules to prevent issues from arising, whereas in passive management by exception, the leader takes action only after issues occur (Richards 2020).
Transactional leadership is often used by nurse leaders and may be the most appropriate style in many situations. For example, it is commonly used in emergency department admissions, where there is a need for rapid decision-making and interventions. According to Cope and Murray (2017), transactional leadership is also effective during crisis situations because these leaders can provide clear direction, make quick decisions and take decisive action. Therefore, during the COVID-19 pandemic, this leadership style could be beneficial because staff are frequently under pressure and many are caring for patients in a critical condition, so they need to act quickly under clear direction.
Transactional leadership has been criticised for its focus on task completion. In nursing, this focus can lead to a non-holistic approach to patient care, because staff will be primarily concerned with the tasks that need to be completed, rather than caring for the patient as a whole (Giltinane 2013).
The task-focused nature of transactional leadership can also negatively affect staff morale, particularly during the COVID-19 pandemic, where staff may be feeling stressed and emotionally exhausted. Therefore, transactional leaders need to be aware that if the negative consequences (such as sanctions and criticism) outweigh the positive effects (such as rewards), staff may feel disempowered and discouraged in relation to their work. For example, during the initial stages of the pandemic, leaders often felt under high pressure to manage limited supplies of personal protective equipment, as well as increased challenges resulting from shortages of experienced staff. As a result, leaders may have adopted a direct and formal style of communication to coordinate the team’s resources, which excluded staff from decision-making. This may have inadvertently lowered staff morale by disempowering their team members and making them feel they were being dictated to rather than guided.
Transformational leaders focus on encouraging changes in the beliefs, values and needs of followers. They believe that followers require a sense of mission or purpose to work effectively and are able to motivate them to act for the ‘greater good’, rather than in their own interests (Burns 1978, Collins et al 2019).
According to Kotter (1990) and Northouse (2021), transformational leadership involves influencing followers, making decisions, being in authority and managing change. A transformational leader perceives staff members’ skills as crucial to achieving the goal and vision of the organisation. They use their personal power to develop a sense of justice, loyalty and trust that motivates their staff (MacKian and Simons 2013).
There are four elements of transformational leadership, often termed the ‘four Is’. These are (Bass 1985, Collins et al 2019):
• Idealised influence – leading by example and setting expectations. This can involve acting as a role model and can enable the leader to develop confidence, admiration, respect and trust in followers.
• Inspirational motivation – inspiring people to reach new heights. This can be achieved by the leader articulating their vision for the team or organisation. This vision needs to appeal to staff members’ emotions and ideals for them to engage with it.
• Intellectual stimulation – encouraging learning and growth. This is achieved by considering team members’ ideas and encouraging them to think creatively in their practice.
• Individualised consideration – coaching and empowering followers to success. This could be achieved by providing feedback to team members to support improvements in performance.
During the COVID-19 pandemic, it has been well documented that many front-line healthcare professionals are experiencing anxiety, fear, insomnia and anger, which increases their risk of burnout (Graham et al 2020). Although transformational leaders are focused on ensuring high-quality patient care is being delivered, they are also concerned about the well-being of individual staff members. Transformational leaders have high levels of emotional intelligence, self-awareness, self-management, social awareness and social skills (Goleman et al 2002). Therefore, they have the ability to consider the emotional needs of the individuals within their team, as well as their own needs. This is important for maintaining the mental health and well-being of staff during the pandemic.
One of the limitations of transformational leadership is that, while some staff may feel inspired by these leaders, others can feel pressured to regularly demonstrate positivity and highly motivated behaviour in their presence (Thompson 2011, Collins et al 2019). The constant pressure to strive towards a grand vision and take pride in the organisation’s achievements may result in some staff becoming demotivated and experiencing burnout, and it may also be emotionally draining for the leader (Collins et al 2019). In the context of the COVID-19 pandemic, the strain on healthcare services can mean that staff may not feel able to strive towards achieving a grand vision.
The laissez-faire leadership style is a non-interference approach in which leaders provide little direction, take no control and offer no support to the team (Marquis and Huston 2009). This type of leader is avoidant, can be challenging to contact, and presents hesitant leadership. Northouse (2021) debated whether the laissez-faire leadership style is an absence of leadership or, as Yang (2015) suggested, a strategic behavioural choice to acknowledge and defer to team members’ abilities and increase their self-competence.
It is important to consider the effects of having no clear direction, or no alignment to a strategic vision, on team members. It has been suggested that some staff may find it challenging to perform under a laissez-faire leader (Whitehead et al 2009, Giltinane 2013), particularly those who require guidance or support. However, experienced team members can potentially thrive under this style of leadership because they require minimal guidance (Whitehead et al 2009, Giltinane 2013).
In relation to the COVID-19 pandemic, a laissez-faire leadership style can mean that highly competent and experienced nurses will be left to continue their work with minimal input from the leader, thus saving time and resources. However, for staff who have less experience, this style of ‘hands-off’ leadership could lead to uncertainty because they may not be given adequate guidance and support, which subsequently could compromise patient care. This style may also lead to ‘in-fighting’ within teams because the laissez-faire leader has abdicated control, thus encouraging staff to compete for power and influence (Deluga 1990).
Compassion has been defined as the feeling that arises in a person when they witness another person’s suffering and that motivates a subsequent desire to provide support (Goetz et al 2010). NHS England (2014) emphasised the importance of placing compassion at the centre of how care is delivered, identifying a clear link between patients who are treated with compassion and staff who are treated with compassion. However, it can be challenging to understand what actions may be taken to implement compassionate leadership in practice, and to develop environments where compassion can thrive.
To foster a compassionate practice environment, leaders have an important role in: ensuring staff are aligned with the organisational purpose; making clear the connection between patient experience and their team’s personal experience of work; and getting to know their team members individually and understanding their needs (NHS England 2014). Leaders also need to be able to notice the concerns of others and have sufficient emotional and practical resources to establish a constructive and supportive team culture (NHS England 2014).
West et al (2017) stated that there are four components of compassion: attending, understanding, empathising and helping. Table 2 describes these components further and explains the actions that compassionate leaders can take in practice.
| Component | Description | Actions that compassionate leaders can take in practice |
|---|---|---|
| Attending | Paying attention to individuals and the team, and noticing their distress | |
| Understanding | Understanding what is causing the individual and/or team’s distress by making an appraisal of the cause | |
| Empathising | Having an empathic response to the individual and/or team’s distress |
|
| Helping | Taking intelligent (thoughtful and appropriate) action to relieve the individual and/or team’s distress |
|
(Adapted from West et al 2017)
Given the emotional challenges and exhaustion among staff that has resulted from the COVID-19 pandemic, it is particularly important for nurse leadership to be centred on compassion. Pelley (2020) asserted that continuing to use traditional ‘command and control’ leadership styles during the pandemic will result in suboptimal outcomes, particularly for people who are vulnerable and marginalised. Pelley (2020) suggested that compassionate leadership is required to:
• Gain a shared understanding of staff experiences from a range of different perspectives and subsequently make decisions based on what they have heard.
• Establish a compassionate and psychologically safe culture where staff can focus on improvement rather than blame.
• Enable everyone within an organisation to have the opportunity to contribute.
• Ensure staff well-being is an organisational priority that will sustain and motivate the workforce.
• Appreciate the needs of teams and how they want to work.
Vogel and Flint (2021) called for leaders to consider the quality of their relationships with their team members, the way in which they support them to feel seen, heard and valued, and how they lead with compassion. This is essential because leaders who display emotional intelligence and put an emphasis on relationships in this manner are more likely to have engaged staff who provide high-quality patient care (Lavoie-Tremblay et al 2016).
The COVID-19 pandemic has resulted in significant challenges for the nursing workforce that have required numerous changes to practice. Effective nurse leadership has been essential during this period to ensure staff are supported and high-quality patient care is provided. The transactional, transformational and laissez-faire leadership styles are commonly used in healthcare, and each style has its benefits and limitations. However, nurse leaders need to consider which leadership style may be the most effective in the context of the pandemic and if they need to adapt their approach. They should also be aware that compassionate leadership may be beneficial to ensure staff feel supported, valued and motivated at this highly stressful time.
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