The Impact of Nurse Leadership Styles
on Nurse Burnout:
A Systematic Literature Review
Holly Wei, PhD, RN, CPN, NEA-BC, Ashley King, MSN, RN-BC,
Yongmei Jiang, MSN, RN, Kerry A. Sewell, MSLS, and
Donna M. Lake, PhD, RN, NEA-BC, FAAN
The purpose of this review is to evaluate the current literature, published 2010 to
2019, and assess the impact of nurse leadership styles on nurse burnout. The review
was guided by the Preferred Reporting Items for Systematic Reviews and MetaAnalyses guidelines. Eighteen articles met the criteria and were reviewed. Based on
the literature, nurse burnout is reported globally, and nurse leadership plays a
significant role in reducing nurse burnout. The major influencing leadership styles
include authentic and transformational leadership. Competent leaders can reduce
nurse burnout through empowering and promoting nurse engagement, applying
authentic and transformational leadership, and creating a healthy work
environment.
A
new landscape is widening within health care
involving value-based care, in which health
professionals, the government, and payers are
under intense pressure to improve patient outcomes
and reduce costs. However, among the efforts in
reducing health care costs, a phenomenon has been
emerging, suboptimal nurse health.1,2 A growing body
of research is uncovering the startling nature of the
mental health issues in nurses, one of which is nurse
burnout.1 Nurse burnout is a work-related stress syndrome characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment.3
Burnout makes nurses lose interest and compassion in what they are doing, which is traumatic in
health care. Physically and emotionally exhausted
nurses can have compromised decision-making, reaction time, and critical thinking,4 as well as increased
absenteeism, turnover, and presenteeism (productivity
loss due to health problems or adverse events).5 The
growing prevalence of nurse burnout has been
recognized as a hazard to health care quality and
patient safety.6 According to the National Academy of
Medicine (NAM), high-quality health care relies on
the well-being, health, and safety of clinicians, and a
core goal is to improve clinicians’ well-being and
reduce burnout.7,8 The Committee on the Future of
Nursing 2020-2030 recognizes nurse burnout as a
significant challenge for nursing currently and in the
next 10 years.9
www.nurseleader.com
To promote a healthy nursing workforce, nurse
leaders play a significant role. Nurse leaders are
considered a centerpiece in facilitating nurses to navigate in the complex health care work environments,
promote their professional growth, and reduce nurse
bunrout.10-12 They are a joining force that has the
influence to gather nurses together and work collaboratively, and they are the ones on whom nurses rely and
from whom nurses seek support.11,13,14 In addition,
nurse leaders are role models in building trust, creating
a healthy and civil work environment, and supporting
nurses, which are crucial to promote nurses’ professional growth and decrease nurse burnout.13,15
KEY POINTS
Nurse leadership plays a significant role in
alleviating nurse burnout.
Authentic and transformational leaderships
are 2 major styles identified to help leaders
demonstrate self-awareness and high moral
standards, which are essential in building
genuine nurse–leader relationships.
Leadership can reduce nurse burnout
through promoting nurse engagement,
applying authentic and transformational
leadership, and creating a healthy nurse
work environment.
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As nurse burnout becomes pervasive, research has
highlighted the relationships between nursing leadership and burnout. To be able to improve leadership
practice, it would be beneficial for nurse leaders to
understand the current state of the science of
leadership-related approaches to combat nurse
burnout. Therefore, a systematic review was conducted, with the purpose to evaluate the current literature
and identify the impact of nurse leadership styles on
nurse burnout.
METHODS
Design
A systematic literature review was guided by the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA).16 We conducted the review
according to Cooper’s17 step-by-step recommendations
for research synthesis.
Databases sources. Databases searched
included Cumulative Index to Nursing and Allied
Health Literature (CINAHL), MEDLINE via
PubMed, PsycINFO, and Google Scholar. Search
terms, phrases, and subject headings were selected
based on the purpose of the review and inclusion
criteria. The following search terms were used:
(“burnout, psychological” [MeSH Terms] OR
“burnout” [tiab]) AND (“leadership” [MeSH Terms]
OR “leadership” [tiab]) AND (“Nurses” [mh] OR
“Nursing” [mh] OR nurse[tiab] OR nurses[tiab] OR
nursing[tiab]).
Inclusion and exclusion. To be included, the
studies had to be primary research data-based and to
have reported the relationships between nurse leadership and burnout. To evaluate the latest evidence, the
studies should be conducted in the last 10 years (2010
to 2019). The last search was conducted on May 20,
2019. The literature search was limited to the English
language. Exclusion criteria were articles focused solely
on either nurse leadership or nurse burnout.
Quality Assessment
The quality of the studies reviewed was assessed by an
appraisal tool for descriptive quantitative studies.18
Each article was evaluated based on the relevance of
the sampling strategy to address the research question,
representation of the sample on the target population,
appropriateness of the measurements, risk of nonresponse bias, and suitability of statistical analysis to
answer the research question. Each criterion was worth
20% for a total of 100%. The higher an article scored,
the better the quality. The scores of articles ranged
from 80% to 100% (Table 1).
RESULTS
After a comprehensive search, we identified and
included 18 articles in this review. As shown in the
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PRISMA flow chart (Figure 1), the initial literature
search generated 490 studies. Three hundred twentyseven articles remained after duplicates were
removed. After titles and abstracts were screened, 29
articles were left for full-text review, after which, 18
studies met the inclusion criteria for the review. These
studies were from 7 countries across the world.
Fostering Employee Engagement
Fostering employee engagement and maintaining a
productive and steady nursing workforce are important
goals for nurse leaders. Leaders have been applying
various leadership styles to promote nurse engagement
and reduce burnout. Even though nurse engagement
and burnout are 2 opposing terms and constructs, they
are significantly related.19 Promoting employee
engagement and building a highly engaged and performing workforce are effective ways to combat nurse
burnout.19-27
Leadership that promotes employee satisfaction
and motivation is effective in reducing nurse burnout.
Higher job satisfaction and lower turnover are noted
when employees are involved in social and teambuilding activities, such as celebrations, social events,
and group learning opportunities.27 Employees with a
promotion focus are more motivated to maximize
their gains at work and concentrate on professional
growth and development, which is linked to lower
burnout.20 In addition, establishing a good fit between
employees and employers, including matching values,
beliefs, and a system of reward and control, can
promote nurse engagement and decrease nurse
burnout.23
Building trust between leaders and nurses and
providing support also show effectiveness in improving
nurse engagement and combating burnout. One way
to build trust and show support is through leadership
WalkRounds, during which nurses are encouraged to
identify issues and provide solutions.21,22 The action of
leadership WalkRounds provides nurses with opportunities to build relationships with leaders and participate
in decision-making, which increases the leader–
follower trust, promotes nurse engagement, and reduces nurse burnout.21 Additionally, being a servant
leader and providing organizational support are positively associated with nurses’ trust in leaders and organizations, which promotes nurses’ involvement and
reduces nurses’ burnout symptoms and intention to
leave.25 Nurses’ perceptions of organizational support
and empowering leadership reduce the negative impacts of burnout symptoms, including emotional
exhaustion and cynicism.24 Nurse leaders play a significant role in supporting and empowering nurses,
promoting engagement, and reducing nurse burnout.26
Promoting nurse engagement and reducing burnout go
hand-in-hand, in which leaders play an irreplaceable
role.
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Table 1. Characteristics and Major Findings of the Articles Reviewed
Author(s)/
Year
Boamah et al.,
201730
Design
Sample
A time-lagged study
405 Canadian new
graduate nurses
Bobbio et al.,
201224
Bobbio &
Manganelli,
201525
Cheng et al.,
201634
Leadership and
Burnout-Related
Instruments
Authentic Leadership
Questionnaire
Maslach Burnout
Inventory–General Survey
Month 2020
A cross-sectional
study
Empowering Leadership
Questionnaire
273 nurses from an
Italian public general
hospital
Maslach Burnout
Inventory–General Survey
A cross-sectional
study
Servant Leadership
Survey
711 nurses from 2
Italian public general
hospitals
Maslach Burnout
Inventory–General Survey
A cross-sectional
study
Multifactor Leadership
Questionnaire
201 RNs at a
metropolitan public
health service in
Victoria, Australia
Oldenburg Burnout
Inventory
Main Findings Related to Nurse Leadership Styles and Nurse
Burnout
Quality
Assessmenta
Authentic leadership had a significant positive direct effect on
structural empowerment, which in turn had a negative direct effect on short-staffing and work–life interference.
The more newly graduated nurses experienced work–life
interference and short-staffing on their units, the more likely they
experienced burnout, felt less satisfied in their jobs, and reported
lower quality of care 1 year later.
Job satisfaction had a significant positive effect on the nurseassessed quality of care.
80%
Supervisors’ perceived empowering leadership style was positively
correlated with nurse perceived organizational support, which had
a joint negative effect on nurses’ job burnout via the mediation of
nurses’ trust in their supervisors and the organization.
Empowering leadership showed a high positive effect on trust in
leaders.
100%
Servant leadership had indirect effects on nurse burnout and
intention to leave via the mediation of trust in leaders.
There were indirect effects of perceived organizational support on
nurse burnout and intention to leave via the mediation of trust in
the organization.
100%
Transformational leadership was significantly negatively correlated
with nurse burnout and turnover intention and significantly positively correlated with perceived quality of care, social identity, and
team climate.
Transformational leadership had a negative relationship with
burnout that influenced nurses’ social identity.
100%
(continued on next page)
3
4
Table 1. (continued)
Month 2020
Author(s)/
Year
Garcia-Rivera
et al., 201335
Laschinger
et al., 201129
Laschinger
et al., 201232
Laschinger
et al., 201431
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Design
Sample
Leadership and
Burnout-Related
Instruments
A cross-sectional
study
Multifactor Leadership
Questionnaire
102 nurses and
doctors from a public
health hospital in
Baja California,
Mexico
Maslach Burnout
Inventory
A cross-sectional
study
LMX-multidimensional
model
3156 staff nurses
from 217 units in 25
acute care hospitals
across Ontario,
Canada
Maslach Burnout
Inventory–General Survey
A cross-sectional
study
Authentic Leadership
Questionnaire
342 new graduate
nurses <2 years of
experience in acute
care hospitals in
Ontario, Canada.
The emotional
exhaustion subscale of
the Maslach Burnout
Inventory-General Survey
A cross-sectional
study
Resonant Leadership
Scale
1241 nurses working
in direct patient care
in Canada
The Maslach Burnout
Inventory–General Survey
Main Findings Related to Nurse Leadership Styles and Nurse
Burnout
Quality
Assessmenta
Transformational leadership had a significant positive association
with a sense of personal accomplishment and was negatively
associated with nurses’ emotional exhaustion and
depersonalization.
There was a positive relationship between passive avoidance
leadership and emotional exhaustion and depersonalization.
Individuals with a passive avoidance leadership style exhibited
higher levels of burnout.
100%
Nurses’ perceptions of the leader-nurse exchange quality on their
units positively affected their perceptions of unit structural
empowerment, which was significantly related to nurses’ higher
levels of job satisfaction.
Unit-level leader–nurse exchange quality was directly related to
nurses’ job satisfaction, which was indirectly related to nurses’
emotional exhaustion and cynicism.
Leaders’ empowerment was associated with lower nurse
emotional exhaustion.
100%
Authentic leadership had a significant negative direct effect on
workplace bullying experiences, which had a significant positive
effect on emotional exhaustion.
Bullying had a negative effect on job satisfaction through
emotional exhaustion.
Job satisfaction was indirectly related to job turnover intentions.
100%
Resonant leadership had a strong positive effect on workplace
empowerment, which had a significant negative effect on
coworker incivility.
Coworker incivility had a significant direct effect on emotional
exhaustion, which in turn, had a significant negative effect on job
satisfaction.
Empowerment influenced nurse job satisfaction directly through
coworker incivility and indirectly through emotional exhaustion.
Resonant leadership had a significant direct effect on job
satisfaction.
100%
(continued on next page)
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Table 1. (continued)
Author(s)/
Year
Laschinger &
Fida, 201428
Laschinger,
et al., 201533
Laschinger &
Read, 201623
Lewis &
Cunningham,
201619
Design
Sample
Time-lagged analysis
Leadership and
Burnout-Related
Instruments
Authentic Leadership
Questionnaire
205 newly graduated
nurses with <2 years
of experience in
acute care hospitals
across Ontario,
Canada
The Emotional
Exhaustion and Cynicism
subscales of the Maslach
Burnout Inventory–
General Survey
A cross-sectional
study
The Authentic Leadership
Questionnaire
1009 new-graduate
nurses <3 years of
experience across
Canada
Maslach Burnout
Inventory–General Survey
A cross-sectional
study
Authentic Leadership
Questionnaire
993 new-graduate
nurses across
Canada
Maslach Burnout
Inventory–General Survey
A cross-sectional
study
Transformational
leadership qualities
120 full-time nurses
at a local hospital
(place not reported)
Maslach Burnout
Inventory–General Scale
Main Findings Related to Nurse Leadership Styles and Nurse
Burnout
Quality
Assessmenta
Workplace bullying was significantly correlated with nurse
burnout and turnover, and burnout dimensions were directly
correlated with turnover dimensions.
Authentic leadership predicted lower levels of work-related
bullying and lower levels of both burnout dimensions.
Higher levels of work-related bullying predicted higher levels of
both emotional exhaustion and cynicism.
Burnout directly affected turnover intention.
100%
Authentic leadership had a direct effect on areas of work–life,
which had a direct effect on new-graduate nurses’ occupational
coping self-efficacy that significantly mediated the effect of areas
of work–life on burnout.
Burnout had a negative effect on nurses’ mental health.
Authentic leadership had significant indirect effects on nurse
burnout and mental health.
100%
Authentic leadership had a positive effect on person–job fit, which
had a positive effect on civility norms.
Civility norms were significant predictors of lower coworker incivility that was associated with higher emotional exhaustion.
100%
Work environment characteristics conditioned the relationship
between transformational leadership and burnout.
The relationship between transformational leadership and
engagement was most strongly conditioned by perceived control,
reward, and value of the areas of work–life framework.
100%
Month 2020
The 1st author was
from Augusta,
Georgia
(continued on next page)
5
6
Table 1. (continued)
Month 2020
Author(s)/
Year
Madathil
et al., 201436
Mudallal
et al., 201726
Sexton et al.,
201422
Design
Sample
A cross-sectional
study
Leadership and
Burnout-Related
Instruments
Maslach Burnout
Inventory–Human
Services Survey
89 psychiatric nurses
from Montana and
New York hospitals
Multifactor Leadership
Questionnaire
A cross-sectional
study
Empowering Behaviors
Scale
407 RNs working in
11 hospitals in
Jordan
Maslach Burnout
Inventory
A cross-sectional
study
SAQ and the HSOPSC
2073 health care
providers (RNs,
physicians, nurse
practitioners, and
therapists) from 44
NICUs
Maslach Burnout
Inventory
Main Findings Related to Nurse Leadership Styles and Nurse
Burnout
Quality
Assessmenta
The transformational leadership style was a significant mediator in
the relationship between depressive symptoms and the personal
accomplishment of burnout.
Depressive symptoms were negatively associated with perceived
transformational leadership style and with the personal accomplishment of burnout.
The transformational leadership style was positively associated
with the personal accomplishment of burnout.
80%
The Jordanian nurses reported high levels of burnout.
The main factors affecting nurses’ feelings of emotional exhaustion were hospital type, department type, and nurse’s work shift.
The highest scores of nurse emotional exhaustion were among
nurses in public hospitals and intensive care units.
Nurses who worked on a fixed shift scored higher on emotional
exhaustion than the nurses who worked on rotating shifts.
Leaders’ empowering behaviors, factors related to work conditions, and nurses’ demographic traits were significantly correlated
with nurse burnout.
100%
Leadership WalkRounds were positively linked to patient safety
culture in the NICUs.
Leadership WalkRounds feedback was correlated with the lower
burnout in the NICUs.
100%
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(continued on next page)
Table 1. (continued)
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Author(s)/
Year
Sexton et al.,
201821
Design
Sample
Leadership and
Burnout-Related
Instruments
A cross-sectional
study
Safety culture domains
measured with SCORE
16,797 health care
professionals (RNs,
physicians, and other
professionals) from
31 hospitals of the
Michigan Health and
Hospital Association,
Michigan
Job Demands–Resources
Questionnaire
Main Findings Related to Nurse Leadership Styles and Nurse
Burnout
Quality
Assessmenta
32.7% of the participating health care professionals reported that
they had participated in leadership WalkRounds, and 24.3%
participated with feedback.
Work settings reporting more WR with feedback had higher safety
culture domain scores and significantly higher engagement scores.
80%
The type of regulatory focus was a significant predictor of nurse
burnout.
Nurses’ perceptions of transformational leadership partially mediated the relationship between nurses’ regulatory focus and
burnout.
Having a promotion focus reduced nurse burnout when nurses
perceived transformational leadership at work.
Having a prevention focus was correlated with more nurse
burnout.
100%
Higher job satisfaction was associated with lower emotional
exhaustion, higher global empowerment, higher organizational
support, higher psychological empowerment, stronger workgroup cohesion, and higher personal accomplishment.
Higher turnover intention was associated with lower job satisfaction, higher emotional exhaustion burnout, more outside job opportunities, weaker work-group cohesion, lower personal
accomplishment, and higher depersonalization.
80%
Elect items on
participation in and
exposure to leadership
WR
Maslach Burnout
Inventory
Shi et al.,
201520
Tourangeau
et al., 201027
Month 2020
A cross-sectional
study
Transformational
Leadership Inventory
378 nurses from 3
hospitals in Shaanxi
Province, China
Maslach Burnout
Inventory–General Survey
A cross-sectional
survey
Maslach Burnout
Inventory
675 long-term care
staff in 26 Ontario
long-term care
facilities
Leadership Practices
Inventory
a
The quality of the studies reviewed was assessed by an appraisal tool for descriptive quantitative studies.15 Each article was evaluated based on the relevance of
the sampling strategy to address the research question, representation of the sample on the target population, appropriateness of the measurements, risk of
nonresponse bias, and suitability of statistical analysis to answer the research question. Each criterion was worth 20% for a total of 100%. The higher an article
scored, the better the quality.
7
HSOPSC, Hospital Survey on Patient Safety Culture; LMX, Leader–Member Exchange; NICU, neonatal intensive care unit; SAQ, Safety Attitudes Questionnaire;
SCORE, Safety, Communication, Operational Reliability and Engagement survey; WR, WalkRound.
Iden fica on
Records iden fied through
database searching
(n = 490)
Addi onal records iden fied
through other sources
(n = 2)
Eligibility
Screening
Records a er duplicates removed
(n = 327)
Records screened via
ar cle tles and abstracts
(n = 327)
Records excluded
(n = 298)
Full-text ar cles assessed
for eligibility
(n = 29)
Full-text ar cles excluded
(n = 11)
Included
Studies included in
qualita ve synthesis
(n = 18)
Figure 1. PRISMA Flow Chart.
Creating a Healthy Work Environment for
Nurses
Although fostering employee engagement is an effective leadership approach in reducing nurse burnout,
creating and maintaining a healthy work environment
is also vital for nurse leaders to promote nurses’ professional growth and physical and psychological health.
When establishing a healthy work environment, nurse
leaders provide nurses with organizational support,
resources, opportunities, and a civil and collaborative
work atmosphere.19,23,28-31
Nurse leadership plays a significant role in
improving nurses’ work environments, which has a
significant impact on nurse burnout. Healthy work
environments, including safe staffing levels, positive
nurse-to-physician relationships, and supportive coworkers and supervisors, significantly influence nurses’
satisfaction.30 Research confirms that short-staffing
affects nurse job dissatisfaction, leading to nursing
burnout and lower quality of patient care.30 An
empowering work environment improves nurses’ access to information, support, and opportunities to learn
and grow, which are related to reduced nurse
burnout.29,31 When organizations provide nurses with
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Month 2020
support, nurses treat organizations’ goals with respect
and are more engaged at work.30,31
In addition, workplace civility is essential in maintaining a productive and steady workforce, and yet,
workplace incivility is frequently reported.28 Nurses
who experience work-related bullying can result in
negative employee and organizational outcomes.28
Nurse leaders are accountable for removing sources
of bullying and creating a work environment with
respectful interpersonal interactions and collaboration.28 A civility norm or culture in a work unit is an
important characteristic of a healthy work environment
in reducing burnout.23 When nurse leaders fail to
communicate positive values or act on situations, the
quality of the work environment deteriorates, and
nurses’ performance and well-being suffer.28 Thus,
establishing and maintaining a healthy work environment is a critical channel for nurse leaders to promote
nurse engagement and reduce nurse burnout.19
Providing Authentic Leadership
One of the major leadership styles studied to reduce
nurse burnout is an authentic leadership style.
Authentic leadership is a relationship-focused
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leadership style characterized by high levels of selfawareness, honesty, transparency, integrity, and consistency.23,28 Nurse leaders with the authentic leadership style are consistent between their actions and their
internal values, care about their employees, and
encourage open and honest conversations.30 Nurses’
perceptions of authentic leadership have a direct relationship with employee empowerment at work, which
in turn improves staffing and work–life balance and
reduces nurse burnout.23,28-30,32,33
An authentic leadership style promotes workplace
civility, which is correlated with reduced nurse
burnout. Authentic leadership behaviors are positively
related to person–job fit, leading to higher perceptions
of civility norms in the workplace and decreased nurse
burnout.23 Authentic leadership is an important factor
in decreasing the likelihood of bullying and burnout,
and thus, improving nurse retention.32 Nurse leaders
with an authentic leadership style try to bring out the
best in employees; they value nurses’ points of view
and encourage nurses to participate in decisionmaking.33
The level of nurse leaders’ authentic leadership has
a direct relationship with nurses’ work–life balance and
coping efficacy and an indirect relationship with nurse
burnout.33 Nurses’ perceptions of nurse–leader relationships positively impact their views about the work
unit empowerment, which improves nurses’ job satisfaction and reduces nurse burnout.29 Thus, applying
an authentic leadership style is considered an effective
approach to promote nurse-leader relationships and
reducing nurse burnout.
Applying Transformational Leadership
Besides the authentic leadership style, transformational
leadership is another major leadership style studied in
reducing nurse burnout. The focus of these studies is
on the effects of transformational leadership on nurse
burnout.20,19,34-36 Transformational leaders encourage
followers to accomplish extraordinary goals through
inspirational motivation, intellectual stimulation, and
individualized consideration; they are innovative in
finding solutions to solve problems and promote positive nurse emotions.
Transformational leadership creates an environment that inspires nurses to perform at their highest
level. Nurse leaders’ transformational leadership is
negatively correlated with nurse burnout and intent-toleave and positively related to nurses’ perceived quality
of care.34 Transformational leadership is significantly
associated with nurses’ healthy work environment,
which is associated with higher nurse engagement and
lower nurse burnout.19 When applying transformational leadership, nurse leaders build a trusting
relationship with nurses and inspire nurses’ engagement and professional growth.19,34
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The transformational leadership style helps relieve
nurses’ burnout symptoms. Nurses’ perceptions of
nurse leaders’ transformational leadership are positively associated with their personal accomplishment
and negatively correlated with their emotional
exhaustion, which are symptoms of nurse burnout.35
Research shows that there are significant relationships
between leadership styles, leaders’ work-role autonomy,
and nurse burnout.36 Nurse leaders’ leadership styles
and nurses’ work-role autonomy are environmental
factors protecting nurses against burnout.36 Therefore,
the application of transformational leadership is shown
as an effective approach to promote nurse performance
and decrease nurse burnout.
DISCUSSION
This review finds that nurse burnout is being studied
and reported globally, and nurse leadership plays a
significant role in reducing nurse burnout. The 2
leadership styles that the literature emphasizes the most
are transformational and authentic leadership. The
findings of this review suggest that nurse leaders’
leadership is a mediator between workload, work environments, and nurse burnout. The mediators of the
leadership styles that help reduce nurse burnout
include building leader–follower trust, providing
organizational support, and creating and maintaining a
healthy work environment.
Nurse leaders play a significant role in promoting
nurse engagement and reducing burnout. Nurse
engagement and burnout have a paradoxical relationship and are closely related.37 Research shows that
nurses see themselves as advocates for patients who are
the center of the nursing care, and promoting patients’
care is a significant motivator for nurses to go to work
and be engaged at work.38 Nurses perceive it a failure if
they do not perform their job well, which contributes to
nurses’ burnout symptoms.37,38 This review finds that
nurse leaders recognize the relationships between nurse
engagement and burnout, and have been exploring
ways to foster nurse engagement. The activities that
nurse leaders implement to promote nurse engagement
include promoting social and team-building activities,
applying leadership WalkRounds, building leader–follower trust, and providing organizational support.
These activities promote the interpersonal relationships
among nurse peers and nurse leaders, which supports a
civil practice environment and personal achievement.13,14,39 Perceived personal accomplishment leads
to greater protection from emotional exhaustion.40
Nurse engagement and performance depend on a
healthy work environment. This review finds that one
of the strategies that nurse leaders use to reduce nurse
burnout is to promote nurses’ practice environment.
Nurses experience a high level of stress in highly
vulnerable work environments.40 The high-level stress
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9
work environments can lead to moral distress, burnout,
and other health issues such as depression and addictions.1 Preventing nurse burnout is a critical goal for
nurse leaders. In addition, strategies for renewal,
including mindfulness practices, and personal resilience plans are impactful in reducing emotional
exhaustion.12,41 Therefore, relational leadership styles
can help nurse leaders focus on interpersonal relationships within a healthy work environment.13,39,42
As nurse leaders continue to face various challenges, they need to be agile in a rapidly changing
health care environment so that they can adapt quickly
to an array of new and challenging situations. Nurses’
job-related stress is prevalent, and nurse leaders play
an important role in alleviating nurses’ stress.43 They
are key players in motivating nurses to apply conflict
resolution tactics, building a highly resilient nurse
workforce, reducing burnout, and improving the
quality of patient care. Appropriate leadership styles
are pivotal in creating a healthy environment, promoting nurse engagement, and decreasing nurse
burnout.44
This review finds that transformational leaders can
engage their followers and establish a trusting relationship. Transformational leaders inspire changes at
workplaces, motivate individuals’ intellect, and stimulate new thinking.37 This review shows that a transformational leader can encourage followers to
accomplish extraordinary goals through inspirational
motivation, genuine communication skills, intellectual
stimulation, and individualized consideration. Nurse
leaders with a transformational leadership style can
help nurses build a sense of belonging and feel safe,
and thus, inspire change.42 Nurse leaders’ transformational leadership style is negatively correlated
with nurse burnout and turnover intention, and positively correlated with perceived quality of care.34
Authentic leadership is another leadership style
examined to reduce nurse burnout. Being an authentic
care leader, one of the relational leadership styles,
transcends values, honesty, trust, and integrity, and has
been reported to be an important connection to
healthy work environments.42 For example, authentic
leaders are critical in building both intra- and interprofessional teams that provide safe patient care by
improving team member engagement, facilitating
communication and trust, and promoting collaborative
practice. Nurse leaders can influence organizational
effectiveness and performance through leadership behaviors.13 Empowering employees to make decisions
about how to do their work can create an environment
of motivation and satisfaction, thus enhancing better
human relationships. An authentic leader can create a
culture of meaningful participation, which can promote nurse engagement and build a team that is
committed to make and implement quality decisions.
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Month 2020
Implications for Nurse Leaders
With a high prevalence of nurse burnout in health
care,45 nurse leaders need to be role models for selfawareness, transparency, and high moral standards.
Self-awareness is an essential aspect of leadership
development, which is achieved through education,
competencies, and mentorship. Self-awareness can
help nurse leaders build relationships with their employees that are genuine and based on care. Transparency is a critical factor that builds trust between the
leader and the employee. In addition, transparent relationships involve staff in the decision-making process.
Most importantly, transparency will assist nurse leaders
in identifying early signs of burnout.
Leaders should create an environment with the
expectation for respectful communication. Interventions should include supporting and implementing policies that have zero-tolerance for workplace
violence and bullying. Nurse leaders should ensure
adequate staffing levels and promote teamwork within
their work environments. Appropriate staffing levels
will help ensure that an employee’s basic needs are
met, such as bathroom and lunch breaks. Leaders
should be strategic during the interview and hiring
process so that they can build a team that works
effectively with each other. For example, nurse leaders
can require an interviewee to do a shadow experience;
this can help determine whether the employee will
work well with the existing team.
Nurse leaders can empower their employees by
performing activities such as employee rounding and
recognition. Employee rounding allows staff to share
both positive and negative aspects of their workday. It is
crucial to gain perspectives from employees regarding
day-to-day operations. In addition, rounding can provide nurse leaders with an opportunity to reinforce
positive behavior through recognition. For example,
nurse leaders can provide staff with a gift, candy, or
thank-you note for exceptional performance. Celebrations and social events are an excellent method to
recognize multiple employees for hard work. Nurse
leaders can empower nurses by providing resources,
support, and opportunities to help them learn and
develop professionally. Leaders can educate employees
about the available financial resources or incentives for
professional development. For example, some health
systems provide nurses with a monetary bonus after
becoming certified in their specialty.
CONCLUSIONS
Nurse burnout is a global issue, and yet, nurse leadership plays a significant role in reducing nurse
burnout. The functions of leadership on nurse burnout
include empowering and supporting nurses, providing
authentic leadership, applying transformational leadership, and creating a team climate for nurses. Nurse
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leaders need to reassess their leadership styles and
provide intellectual stimulation to influence nurses.
Transformational and authentic leadership styles
demonstrate effectiveness in inspiring and motivating
nurses. Transformational and authentic leaders can
foster nurse engagement, improve nurse satisfaction,
and reduce nurse burnout, which ultimately promotes
patient quality of care and outcomes.
REFERENCES
1. Melnyk BM. Burnout, depression and suicide in nurses/clinicians and learners: an urgent call for action to enhance professional well-being and healthcare safety. Worldviews Evid
Based Nurs. 2020;17(1):2-5.
2. Bodenheimer T, Sinsky C. From triple to quadruple aim: care
of the patient requires care of the provider. Ann Fam Med.
2014;12(6):573-576.
3. Maslach C, Leiter MP. Understanding the burnout experience:
recent research and its implications for psychiatry. World
Psychiatry. 2016;15(2):103-111.
4. Drake DA, Luna M, Georges JM, Steege LMB. Hospital nurse
force theory: a perspective of nurse fatigue and patient harm.
ANS Adv Nurs Sci. 2012;35(4):305-314.
5. Yang T, Ma M, Zhu M, et al. Challenge or hindrance: does job
stress affect presenteeism among Chinese healthcare
workers? J Occup Health. 2018;60(2):163-171.
6. Boytim J, Ulrich B. Factors contributing to perioperative
medication errors: a systematic literature review. AORN J.
2018;107(1):91-107.
7. National Academy of Medicine. Action Collaborative on
Clinician Well-Being and Resilience. Available at: https://nam.
edu/initiatives/clinician-resilience-and-well-being/. Accessed
March 4, 2020.
8. National Academies of Sciences, Engineering, and Medicine.
Taking Action Against Clinician Burnout: A Systems Approach
to Professional Well-Being. Washington, DC: National Academies Press; 2019.
9. National Academy of Medicine. Public Session for the Committee on the Future of Nursing 2020-2030. Available at:
https://nam.edu/event/public-session-for-the-committee-onthe-future-of-nursing-2020-2030/. Accessed March 4, 2020.
10. Sherman RO. Nurse leaders as makers. Nurse Leader.
2018;16(6):358-359.
11. Warshawsky NE. Nursing leadership: state of the science.
J Nurs Adm. 2019;49(5):229-230.
12. Wei H, Roberts P, Strickler J, Corbett RW. Nurse leaders’ strategies
to foster nurse resilience. J Nurs Manag. 2019;27(4):681-687.
13. Wei H, Sewell KA, Woody G, Rose MA. The state of the science of nurse work environments in the united states: a systematic review. Int J Nurs Sci. 2018;5(3):287-300.
14. Warshawsky NE, Wiggins AT, Rayens MK. The influence of the
practice environment on nurse managers’ job satisfaction and
intent to leave. J Nurs Adm. 2016;46(10):501-507.
15. American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2nd ed. Aliso Viejo, CA:
American Association of Critical-Care Nurses; 2016.
16. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group.
Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. PLoS Med.
2009;6(7):e1000097.
17. Cooper HM. Research Synthesis and Meta-Analysis: A
Step-by-Step Approach. 5th ed. Los Angeles, CA: SAGE
Publications; 2017.
18. Hong QN, Gonzalez-Reyes A, Pluye P. Improving the usefulness of a tool for appraising the quality of qualitative,
www.nurseleader.com
quantitative and mixed methods studies, the mixed
methods appraisal tool (MMAT). J Eval Clin Pract.
2018;24(3):459-467.
19. Lewis HS, Cunningham CJL. Linking nurse leadership and
work characteristics to nurse burnout and engagement. Nurs
Res. 2016;65(1):13-23.
20. Shi R, Zhang S, Xu H, Liu X, Miao D. Regulatory focus and
burnout in nurses: The mediating effect of perception of
transformational leadership. Int J Nurs Pract. 2015;21(6):
858-867.
21. Sexton JB, Adair KC, Leonard MW, et al. Providing feedback
following leadership WalkRounds is associated with better
patient safety culture, higher employee engagement and
lower burnout. BMJ Qual Saf. 2018;27(4):261-270.
22. Sexton JB, Sharek PJ, Thomas EJ, et al. Exposure to leadership
WalkRounds in neonatal intensive care units is associated with
a better patient safety culture and less caregiver burnout. BMJ
Qual Saf. 2014;23(10):814-822.
23. Laschinger HKS, Read EA. The effect of authentic leadership,
person-job fit, and civility norms on new graduate nurses’
experiences of coworker incivility and burnout. J Nurs Adm.
2016;46(11):574-580.
24. Bobbio A, Bellan M, Manganelli AM. Empowering leadership,
perceived organizational support, trust, and job burnout for
nurses: a study in an Italian general hospital. Health Care
Manage Rev. 2012;37(1):77-87.
25. Bobbio A, Manganelli AM. Antecedents of hospital nurses’
intention to leave the organization: A cross sectional survey.
Int J Nurs Stud. 2015;52(7):1180-1192.
26. Mudallal RH, Othman WM, Al Hassan NF. Nurses’ burnout:
the influence of leader empowering behaviors, work conditions, and demographic traits. Inquiry. 2017;54:
46958017724944.
27. Tourangeau A, Cranley L, Laschinger HKS, Pachis J. Relationships among leadership practices, work environments, staff
communication and outcomes in long-term care. J Nurs
Manag. 2010;18(8):1060-1072.
28. Laschinger HKS, Fida R. A time-lagged analysis of the effect of
authentic leadership on workplace bullying, burnout, and
occupational turnover intentions. Eur J Work Organ Psychology. 2014;23(5):739-753.
29. Laschinger HKS, Finegan J, Wilk P. Situational and dispositional influences on nurses' workplace well-being: the role of
empowering unit leadership. Nurs Res. 2011;60(2):124-131.
30. Boamah SA, Read EA, Laschinger HKS. Factors influencing
new graduate nurse burnout development, job satisfaction
and patient care quality: a time-lagged study. J Adv Nurs.
2017;73(5):1182-1195.
31. Laschinger HKS, Wong CA, Cummings GG, Grau AL. Resonant leadership and workplace empowerment: the value of
positive organizational cultures in reducing workplace incivility. Nurs Econ. 2014;32(1):5.
32. Laschinger HKS, Wong CA, Grau AL. The influence of
authentic leadership on newly graduated nurses’ experiences
of workplace bullying, burnout and retention outcomes: a
cross-sectional study. Int J Nurs Stud. 2012;49(10):12661276.
33. Laschinger HKS, Borgogni L, Consiglio C, Read E. The effects
of authentic leadership, six areas of worklife, and occupational coping self-efficacy on new graduate nurses’ burnout
and mental health: a cross-sectional study. Int J Nurs Stud.
2015;52(6):1080-1089.
34. Cheng C, Bartram T, Karimi L, Leggat S. Transformational
leadership and social identity as predictors of team climate,
perceived quality of care, burnout and turnover intention
among nurses. Personnel Rev. 2016;45(6):1200-1216.
35. Garcia-Rivera BR, Alejandro Mendoza-Martinez IA, RamirezBaron MC. The impact of transformational leadership in
Month 2020
11
burnout of nurses and doctors in a public hospital of Mexico.
Am J Health Sci. 2013;4(1):1-12.
36. Madathil R, Heck NC, Schuldberg D. Burnout in psychiatric
nursing: examining the interplay of autonomy, leadership
style, and depressive symptoms. Arch Psychiatr Nurs.
2014;28(3):160-166.
37. Vinje HF, Mittelmark MB. Job engagement's paradoxical role
in nurse burnout. Nurs Health Sci. 2007;9(2):107.
38. Wei H, Kifner H, Dawes ME, Wei TL, Boyd JM. Selfcare strategies to combat professional burnout by pediatric critical care
nurses and physicians. Crit Care Nurse. 2020;40(2):1-11.
39. Warshawsky NE, Havens DS, Knafl G. The influence of interpersonal relationships on nurse managers’ work engagement
and proactive work behavior. J Nurs Adm. 2012;42(9):418-425.
40. Rushton CH, Batcheller J, Schroeder K, Donohue P. Burnout
and resilience among nurses practicing in high-intensity settings. Am J Crit Care. 2015;24(5):412-420.
41. Wei H, Corbett RW, Ray J, Wei TL. A culture of caring: the
essence of healthcare interprofessional collaboration.
J Interprof Care. 2020;34(3):324-331.
42. Raso R. Be you! Authentic leadership. Nurs Manage.
2019;50(5):18-25.
43. Leng M, Xiu H, Yu P, et al. The current state and influencing
factors of nurse resilience and perceived job-related stressors.
J Contin Educ Nurs. 2020;51(3):132-137.
44. Zopiatis A, Constanti P. Leadership styles and burnout: is there
an association? Int J Contemp Hospital Manage.
2010;22(3):300-320.
12
Month 2020
45. Bakhamis L, Paul DP, Smith H, Coustasse A. Still an epidemic:
the burnout syndrome in hospital registered nurses. Health
Care Manag. 2019;38(1):3-10.
Holly Wei, PhD, RN, CPN, NEA-BC, is associate professor,
Nurse Leadership Concentration, Department of
Advanced Nursing Practice and Education, at the College
of Nursing, East Carolina University Greenville, in
Greenville, North Carolina. She can be reached at
weih16@ecu.edu. Ashley King, MSN, RN-BC, is clinical
nurse IV at Duke Regional Hospital in Durham, North
Carolina. Yongmei Jiang, MSN, RN, is vice chair of the
Infection Control Department at the Affiliated Hospital of
Qingdao University in Qingdao, China. Kerry A. Sewell,
MSLS, is research librarian, Laupus Library, at East
Carolina University Greenville. Donna M. Lake, PhD, RN,
NEA-BC, FAAN, is professor, Department of Advanced
Nursing Practice and Education, at the College of
Nursing, East Carolina University Greenville.
1541-4612/2020/$ See front matter
Copyright 2020 by Elsevier Inc.
All rights reserved.
https://doi.org/10.1016/j.mnl.2020.04.002
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