International Journal of

Environmental Research
and Public Health

Review
Leadership Styles and Nurses’ Job Satisfaction. Results of a
Systematic Review
Maria Lucia Specchia 1,2 , Maria Rosaria Cozzolino 2,3, * , Elettra Carini 2 , Andrea Di Pilla 2 , Caterina Galletti 2 ,
Walter Ricciardi 1,2 and Gianfranco Damiani 1,2

1 Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli
IRCCS, Via della Pineta Sacchetti, 00168 Rome, Italy; [email protected] (M.L.S.);
[email protected] (W.R.); [email protected] (G.D.)
2 Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Largo Francesco Vito, 00168 Rome,
Italy; [email protected] (E.C.); [email protected] (A.D.P.);
[email protected] (C.G.)
3 Emergency Department, Barking, Havering and Redbridge University Hospitals Trust, Rom Valley Way,
Romford RM70AG, UK
* Correspondence: [email protected]; Tel.: +39-3343060463

Abstract: Healthcare organisations are social systems in which human resources are the most im-
portant factor. Leadership plays a key role, affecting outcomes for professionals, patients and work
environment. The aim of this research was to identify and analyse the knowledge present to date
concerning the correlation between leadership styles and nurses’ job satisfaction. A systematic review
was carried out on PubMed, CINAHL and Embase using the following inclusion criteria: impact
of different leadership styles on nurses’ job satisfaction; secondary care; nursing setting; full-text



available; English or Italian language. From 11,813 initial titles, 12 studies were selected. Of these,


88% showed a significant correlation between leadership style and nurses’ job satisfaction. Trans-
Citation: Specchia, M.L.; Cozzolino, formational style had the highest number of positive correlations followed by authentic, resonant
M.R.; Carini, E.; Di Pilla, A.; Galletti, C.;
and servant styles. Passive-avoidant and laissez-faire styles, instead, showed a negative correlation
Ricciardi, W.; Damiani, G. Leadership
with job satisfaction in all cases. Only the transactional style showed both positive and negative
Styles and Nurses’ Job Satisfaction.
correlation. In this challenging environment, leaders need to promote technical and professional
Results of a Systematic Review. Int. J.
Environ. Res. Public Health 2021, 18,
competencies, but also act to improve staff satisfaction and morale. It is necessary to identify and fill
1552. https://doi.org/10.3390/ the gaps in leadership knowledge as a future objective to positively affect health professionals’ job
ijerph18041552 satisfaction and therefore healthcare quality indicators.

Academic Editor: Paul B. Tchounwou Keywords: leadership; job satisfaction; nursing

Received: 14 January 2021
Accepted: 2 February 2021
Published: 6 February 2021
1. Introduction
Publisher’s Note: MDPI stays neutral In a constantly challenging environment, healthcare systems are expected to achieve
with regard to jurisdictional claims in
the often competing aims of improving public health, while simultaneously avoiding
published maps and institutional affil-
increases in health spending [1]. Several studies have shown that managers’ approach
iations.
and leadership styles may influence both staff performance and healthcare system per-
formance metrics [2]. Despite this, questions remain regarding the relationship between
leadership styles and variables such as job satisfaction, commitment, and performance
among healthcare staff.
Copyright: © 2021 by the authors. In general, leadership is defined as the art of influencing others to achieve their
Licensee MDPI, Basel, Switzerland. maximum potential to accomplish any task, objective, or project [3]. Leadership theories
This article is an open access article
have historical roots and have developed, presenting different peculiarities over time, as
distributed under the terms and
people and historical circumstances have changed [4]. Over the years, different leadership
conditions of the Creative Commons
styles have evolved, such as:
Attribution (CC BY) license (https://
Transformational: Characterised by charismatic influence, effective communication, val-
creativecommons.org/licenses/by/
orisation of relationships, and individualised consideration. Leaders know how to convey
4.0/).

Int. J. Environ. Res. Public Health 2021, 18, 1552. https://doi.org/10.3390/ijerph18041552 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 1552 2 of 15

a sense of loyalty through shared goals, and this results in increased productivity, improved
morale and employees’ job satisfaction [5]. Transformational leaders use idealized influ-
ence, inspiration and motivation, intellectual stimulation, and individualized consideration
to achieve superior results. They motivate others to do more than they originally intended
and often more than they thought possible [6]. Transformational leaders work to inspire
their followers to look past their own self-interest and to perform above expectations to
promote team and organizational interests [7].
Transactional: Characterised by processes of recognition, reward or punishment, cor-
rective actions by the leader based on how the employees perform the tasks assigned to
them. Staff generally work independently, there is no cooperation between employees who
show a commitment to the organisation in the short term [8]. Transactional leadership
fails to build trust between the leader and the follower; it does not require a leader to
take the ethical and moral road and relies on extrinsically motivating the employee to
work for his or her personal interest [7]. The main goal of such leadership is to come to
an agreement on a series of actions that meet the separate and immediate aims of both
the leader and the followers. Transactional leadership is accompanied by features like
immobility, self-attraction and controlling the subordinates [9].
Laissez-faire: It is a subgroup of transactional style characterised by an attitude to avoid
any responsibility and involvement. Known as “absence of leadership”, it is considered
ineffective because it reduces the trust in supervisors and organisations [10]. It is a type
of leadership in which followers are given complete freedom to make decisions in the
leader’s absence. That is why it is considered the most passive type of leadership within
the leadership spectrum [9].
Servant: This model encourages the professional growth of professionals and simulta-
neously promotes the improved delivery of healthcare services through a combination of
interdisciplinary teamwork, shared decision making, and ethical behaviour [11]. Through
empathy, listening to others, commitment to grow people and building community, along
with their moral core, servant leaders try to help others achieve their goals and overcome
challenges [7]. They share power, put the needs of others first, help individuals develop and
optimize performance. They concentrate on performance planning, day-to-day coaching,
and are willing to learn from others forsaking personal advancement and rewards [12].
Resonant: Defined as the behaviour of leaders who demonstrate a high level of emo-
tional intelligence. They are in tune with the emotions of those around them, use empathy
and manage their own emotions effectively to build strong, trusting relationships and cre-
ate a climate of optimism that inspires commitment [13]. Resonant leaders coach, develop,
inspire, and include others even in the case of adversity, using their emotional intelligence.
They create an environment where others are highly engaged, making them willing and
able to contribute with their full potential [6,14].
Passive-avoidant: Characterised by a leader who avoids taking responsibility and
confronting others. Employees perceive the lack of control over the environment resulting
from the absence of clear directives. Organisations with this type of leader have high staff
turnover and low employees retention [15]. They tend to react only after problems have
become serious to take corrective action, and often avoid making any decisions at all [6].
Authentic: Characterised by a leader with an honest and direct approach. The key
elements are: self-awareness, internalised moral perspective, balanced processing, and
relational transparency [16]. This model is a leader’s non-authoritarian, ethical, and trans-
parent behaviour pattern. It strives for trusting, symmetrical, and close leader–follower
relationships and promotes the open sharing of information and consideration of employ-
ees’ viewpoints [17].
Nurses’ job satisfaction should be a topic of paramount importance for healthcare
organisations and their stakeholders as they represent the largest professional body of
workers within healthcare systems. Several studies show that improving their job satisfac-
tion should be a key objective in facing challenges related to achieving and maintaining
quality standards, ensuring patient satisfaction and staff retention [18–20]. Although many
Int. J. Environ. Res. Public Health 2021, 18, 1552 3 of 15

published studies emphasise the importance of leadership, only a few have related the
leadership styles to their effects on nurses’ job satisfaction. This research aimed to identify
and analyse, through a systematic review of the literature, the current knowledge of the
correlation between leadership styles and nurses’ job satisfaction.

2. Materials and Methods

A systematic review was performed following the PRISMA statement in order to
summarise the existing literature about the correlation between leadership styles and
nurses’ job satisfaction.

2.1. Search Strategy

The authors used the PICO model to describe all the components related to the
identified problem and to structure the research question. PICO represents an acronym
that stands for: Patient, Intervention, Comparison, and Outcome. These four components
are the essential elements of the research question in Evidence-Based Practice for the
construction of the question for the bibliographic search of evidence [21,22].
In this study, the research question was composed by PIO, in detail: (P) Nurses em-
ployed in hospital contexts; (I) use of different leadership styles by nurse coordinators,
managers, and leaders; (O) effects on nurses’ satisfaction regarding their job. In order to an-
swer the research question, Pubmed, CINAHL, and Embase databases were searched using
the following string: (nurs* OR personnel OR staff OR patient OR healthcare professional
OR employee) AND (leader*) AND (impact OR safety OR satisfaction OR empowerment
OR performance OR attitude OR outcome) AND (hospital OR secondary care OR depart-
ment OR division OR directorate OR ward OR service OR unit). The search was limited
to “title/abstract” and “humans” in PubMed while no limits were set in CINHAL and
Embase. No filters have been set regarding the year of publication, or regarding the type of
studies.
All the resulting records published up to 22 October 2019 were screened by two
independent researchers (MRC and EC). Articles were selected by first reading the title and,
if deemed suitable, the abstract before finally reading the full text. Eventual uncertainties,
regarding article inclusion, were overcome by discussion amongst the research members.

2.2. Inclusion/Exclusion Criteria

Only studies published in English and Italian, related to hospital settings, nursing
focused, primary studies that have investigated a correlation between leadership styles
and nurses’ job satisfaction and with availability of full text were included. The following
were set as exclusion criteria: commentary study designs; articles examining leadership
styles but not referring to nurses; that described effects on the leader and not on personnel;
and articles that analysed effects on healthcare workers other than job satisfaction.

2.3. Data Synthesis

Data were entered into a spread sheet on Microsoft® Excel and collated in a table
which, for each article, specified the author(s), year of publication, country of origin, study
design, sample, methods, results, and limitations of the study.

2.4. Quality Appraisal

The quality assessment was performed with the Quality Assessment Tool for Observa-
tional Cohort and Cross-Sectional Studies [23]. This scale consists of 14 questions with three
possible answers: ‘yes’, ‘no’, and ‘other (cannot determine, not applicable, not reported)’.
The tool evaluates the internal validity of a study, considering the risk of potential bias.
After the evaluation of each criteria, the reviewer judges each study to be of ‘good’, ‘fair’,
or ‘poor’ quality. A study is rated ‘good’ if the study is thought to have the least risk of
bias; ‘fair’ if susceptible to some bias, which is not sufficient to invalidate the results; and
‘poor’, when there is significant risk of bias. Since the tool did not provide a clear definition
Int. J. Environ. Res. Public Health 2021, 18, 1552 4 of 15

of the method for the evaluation of the studies, we rated the quality of the studies based on
the calculation of the tertiles of the number of items on the quality scale. The score was
attributed based on the number of “yes” present and was assigned “poor” for scores falling
in the lowest tertile, “fair” in the intermediate tertile, and “good” in the highest tertile.
Quality was independently evaluated by two researchers (MRC and EC) with dis-
agreements discussed until consensus was reached.

3. Results
The initial search yielded 3146 records on PubMed, 5195 on CINAHL, and 4844 on
Embase. After removal of duplicates, the final records were 11,813. The selection by title
reduced the eligible articles to 556 and further evaluation by abstract brought the total
to 60 full texts. The aim of the research was to select only primary studies that have
investigated the specific correlation between leadership styles and nurses’ job satisfaction.
This contributed to the significant reduction in the number of records. In fact, only 12
studies, satisfying the stated inclusion/exclusion criteria, met the precise constraints of
the18,
Int. J. Environ. Res. Public Health 2021, research question
x FOR PEER REVIEW and were eligible for the final qualitative synthesis. The5process
of 15 of
identification, selection, and exclusion of the articles is shown in Figure 1.

Figure1.1.PRISMA
Figure PRISMA Flowchart
Flowchart ofofarticles
articles selection.
selection.

Within the selected studies, there were seven leadership styles analysed: authentic,
laissez-faire, passive-avoidant, resonant, servant, transactional, and transformational.
Eight articles analysed more than one leadership style (from two up to four), whilst four
analysed just the effects of one specific style: authentic [34], resonant [27], servant [26],
and transformational leadership [35]. The transformational and the transactional lead-
Int. J. Environ. Res. Public Health 2021, 18, 1552 5 of 15

Of the 12 selected studies, two (17%) were from PubMed, whilst the remaining 10
(83%) were from CINAHL. The studies included were published between 1995 and 2017
with 92% of them published within the last 8 years. Three quarters of the studies were
journal articles and the remaining were dissertations [24–26]. All the studies could be
classified as cross-sectional. In 83% of the cases, questionnaires were the tool used to
evaluate job satisfaction in relation to managers’ leadership styles. Half of the studies were
from North America (four from USA and two from Canada), two from Saudi Arabia, one
from China, one from Ethiopia, one from Italy, and one from Jordan.
The sample size was from 83 [25] to 1216 participants [27], though in most of the
studies (42%) the sample size was between 200 and 308. The Multifactor Leadership
Questionnaire (MLQ) [24,25,28–33] was used in 8 out of 12 studies (67%). Other studies
(33%) used the Job Satisfaction Survey (JSS) either alone [26,34] or in combination with
MLQ [28,32].
Within the selected studies, there were seven leadership styles analysed: authentic,
laissez-faire, passive-avoidant, resonant, servant, transactional, and transformational. Eight
articles analysed more than one leadership style (from two up to four), whilst four analysed
just the effects of one specific style: authentic [34], resonant [27], servant [26], and trans-
formational leadership [35]. The transformational and the transactional leadership styles
were the most frequently evaluated, appearing in 75% and 67% of the studies, respectively,
followed by passive-avoidant (25%) and laissez-faire (25%).
Varying leadership styles were found to have positive, negative, or equivocal effects
on nurses’ job satisfaction. Results are shown in Table 1.

Table 1. Correlation between leadership styles and job satisfaction.

Leadership Positive Negative Total Number

No Correlation
Style Correlation Correlation of Studies
Abdelhafiz, 2016
Alshahrani, 2016
Abualrub, 2012
Bormann, 2011
Transformational Despres, 2011 - - 9
Medley, 1995
Morsiani, 2017
Nebiat, 2013
Wang, 2012
Abdelhafiz, 2016
Bormann, 2011
Alshahrani, 2016
Transactional Despres, 2011 Abualrub, 2012 8
Morsiani, 2017
Medley, 1995
Nebiat, 2013
Abdelhafiz, 2016
Laissez-faire - - Morsiani, 2017 3
Nebiat, 2013
Abdelhafiz, 2016
Passive- - - Bormann, 2011 3
avoidant
Despres, 2011
Authentic Wong, 2013 - - 1
Resonant Bawafaa, 2015 - - 1
Servant Mitterer, 2017 - - 1

Of the selected studies, 88% showed a positive or negative statistically significant

correlation between leadership style and nurses’ job satisfaction. The transformational style
had the greatest positive correlation in 9 out of 9 of cases. Also, authentic, resonant, and
servant styles demonstrated positive correlation in 1 out of 1 case each. On the other hand,
passive-avoidant and laissez-faire styles showed a negative correlation with job satisfaction
Int. J. Environ. Res. Public Health 2021, 18, 1552 6 of 15

in all cases (1 out of 1 each). Only in the transactional leadership style the relationship with
job satisfaction was equivocal. In fact, in 3 out of 8 cases (37%) no significant correlation
was found, while in 1 out of 8 cases (13%) there was a negative correlation. A positive
association with this style, instead, has been found in 4 out of 8 of the studies (50%).
Details about year of publication, country, study design, sample size, methods, results,
and limitations of the selected articles are shown in Table 2.

Table 2. Analysis of the studies included.

Study Design,
Authors, Country Methods Results Limitations
Sample Size
Articles
Positive correlation
between Transformational
- Multifactor
Leadership and job
Medley F, Larochelle D, Leadership
Cross-sectional satisfaction (r = 0.401; p < - Quality assessed as
(1995) Questionnaire (MLQ);
n = 122 nurses 0.001); “FAIR”
USA - Index of Work
No correlation with
Satisfaction (IWS).
Transactional Leadership
style (r = 0.047; p < 0.001)
- Convenience sample
- Multifactor
Positive correlation selected from 6
Leadership
between Transformational hospitals (results not
Questionnaire
Leadership and job generalisable);
Abualrub RF, (MLQ-5X);
Cross-sectional satisfaction (r = 0.45; p < - Data collected after
Alghamdi MG (2012) - Job Satisfaction Survey
n = 308 nurses 0.01); recalling participants
Saudi Arabia (JSS);
Negative correlation with (reporting bias
- Statistical Package for
Transactional Leadership possibility)
Social Sciences (SPSS)
(r = −0.14; p < 0.01) - Quality assessed as
17.0 version.
“FAIR”
- Leadership Practice
Positive correlation
Inventory (LPI);
Wang X, Chontawan R, between Transformational
Cross-sectional - Job Satisfaction Scale; - Quality assessed as
Nantsupawat R, (2012) Leadership and job
n = 238 nurses - Statistical Package for “FAIR”
China satisfaction (r = 0.556; p <
Social Sciences (SPSS)
0.001)
13.0 version.
- Multifactor
Positive correlation with
Leadership
Transformational (r = 0.51;
Questionnaire
p < 0.01) and Transactional
Nebiat N, (MLQ-5X);
Cross-sectional Leadership style (β = 0.45, - Quality assessed as
Asresash, D, (2013) - Minnesota Satisfaction
n = 175 nurses p < 0.01); “FAIR”
Ethiopia Questionnaire (MSQ);
Negative correlation with
- Statistical Package for
Laissez-faire style (r =
Social Sciences (SPSS)
−0.19; p < 0.05).
16.0 version.
- The cross-sectional
design limits the
explanations of causal
- Authentic Leadership effects of covariation of
Questionnaire; Positive correlation the variables and of the
Wong CA, Laschinger - Global Job Satisfaction between Authentic proposed theoretical
Cross-sectional
H, (2013) Survey; Leadership and job associations;
n = 280 nurses
Canada - Statistical Package for satisfaction (β = 0.16; p < - Use of self-report
Social Sciences (SPSS) 0.01) measures does not
19.0 version. allow to exclude
variation probability
- Quality assessed as
“FAIR”
Int. J. Environ. Res. Public Health 2021, 18, 1552 7 of 15

Table 2. Cont.

Study Design,
Authors, Country Methods Results Limitations
Sample Size
- The cross-sectional
design limits the
explanations of causal
- Resonant Leadership effects of covariation of
Scale; Positive correlation the variables and of the
Bawafaa E, Wong CA, - General Satisfaction between Resonant proposed theoretical
Cross-sectional
Laschinger H, (2015) Subscale; Leadership and job associations;
n = 1216 nurses
Canada - Statistical Package for satisfaction (r = 0.43; p < - Low answer rate to
Social Sciences (SPSS) 0.001) the survey (low
20.0 version. generalisability of the
results)
- Quality assessed as
“FAIR”
Positive correlation of job
satisfaction with both
Transformational
- Multifactor Leadership (r = 0.374; p <
Abdelhafiz IM,
Leadership 0.001) and Transactional
Alloubani AM, Cross-sectional - Quality assessed as
Questionnaire style (r = 0.391; p < 0.001);
Almatari M (2016) n = 200 nurses “FAIR”
(MLQ-5X); Negative correlation with
Jordan
- Job Satisfaction Tool. Passive-avoidant (r =
−0.240; p < 0.001) and with
Laissez-faire styles (r =
−0.225; p < 0.001).
Positive correlation
- Multifactor
between Transformational
Leadership
Leadership and job
Questionnaire
satisfaction (r = 0.78; p <
Alshahrani FMM, Baig (MLQ-5X);
Cross-sectional 0.01); - Quality assessed as
LA (2016) - Job Satisfaction Survey
n = 89 nurses Positive correlation “FAIR”
Saudi Arabia (JSS);
between transactional
- Statistical Package for
leadership and job
Social Sciences (SPSS)
satisfaction (r = 0.50; p <
20.0 version.
0.01)
Positive correlation
between Transformational
Leadership and job
- Convenience sample
- Multifactor satisfaction (r = 0.71; p <
chosen from 3 hospitals
Morsiani G, Bagnasco Leadership 0.01);
Cross-sectional (results not
A, Sasso L, (2017) Questionnaire Positive correlation with
n = 87 nurses generalisable)
Italy (MLQ-5X); Transactional style (r = 0.55;
- Quality assessed as
- STATA 12.0 version. p < 0.01);
“FAIR”
Negative correlation with
Laissez-faire style (r =
−0.42, p < 0.01)
Int. J. Environ. Res. Public Health 2021, 18, 1552 8 of 15

Table 2. Cont.

Study Design,
Authors, Country Methods Results Limitations
Sample Size
Dissertations
- Data related to nurses’
perceptions rather than
Positive correlation to real leadership
between Transformational behaviour;
- Multifactor
Leadership and job - Convenience sample
Leadership
satisfaction (r = 0.296; p < chosen from non-profit
Questionnaire (MLQ);
Bormann LB, (2011) Cross-sectional 0.01); hospitals (results not
- Job In General (JIG)
USA n = 115 nurses Negative correlation with generalisable);
Scale;
Passive-avoidant style (r = - Low rate of response
- Job Descriptive Index
−0.413; p < 0.01); to the survey (low
(JDI).
No correlation with generalisability of the
Transactional Leadership results)
- Quality assessed as
“FAIR”
- Convenience sample
(results not
generalisable);
Positive correlation
- Multifactor - Voluntary
between Transformational
Leadership participation
Leadership and job
Questionnaire (non-participant bias);
satisfaction (r = 0.419; p <
(MLQ-5X); - Validity of the study
Despres KK, (2011) Cross-sectional 0.05);
- Job In General (JIG) limited to the reliability
USA n = 83 nurses Negative correlation with
Scale; of the used tools;
Passive-avoidant style (r =
- Job Descriptive Index - Low rate of response
−0.419; p < 0.05);
(JDI); to the survey (low
No correlation with
- JMP 5.0 version. generalisability of the
Transactional style
results)
- Quality assessed as
“FAIR”
- Self-reporting
(reporting bias);
- Cross-sectional design
limits the explanations
- Servant Leadership of causal effects and
Survey e Scale; covariations of
Positive correlation
- Job Satisfaction Survey variables;
between Servant
Mitterer DM, (2017) Cross-sectional and Job satisfaction - Voluntary
Leadership and job
USA n = 283 nurses Score; participation
satisfaction (r = 0.44; p <
- Statistical Package for (non-participant bias);
0.01)
Social Sciences (SPSS) - On-line survey
23.0 version. (excludes all the people
not familiar with
technology)
- Quality assessed as
“FAIR”

Regarding quality assessment results, all studies were found to be of fair quality.
Details about quality assessment are shown in Table 3.
Int. J. Environ. Res. Public Health 2021, 18, 1552 9 of 15

Table 3. Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

Articles Dissertations
Medley, Abualrub, Wang, Nebiat, Wong, Bawafaa, Abdelhafiz, Alshahrani, Morsiani, Bormann, Despres, Mitterer,
Criteria
1995 2012 2012 2013 2013 2015 2016 2016 2017 2011 2011 2017
1. Was the research question or objective
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
in this paper clearly stated?
2. Was the study population clearly
No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
specified and defined?
3. Was the participation rate of eligible
No Yes Yes Yes No No Yes Yes Yes No No No
persons at least 50%?
4. Were all the subjects selected or
recruited from the same or similar
populations (including the same time
No Yes Yes Yes Yes Yes Yes NS Yes Yes Yes Yes
period)? Were inclusion and exclusion
criteria for being in the study prespecified
and applied uniformly to all participants?
5. Was a sample size justification, power
description, or variance and effect No Yes No NA No No Yes Yes No Yes Yes Yes
estimates provided?
6. For the analyses in this paper, were the
exposure(s) of interest measured prior to No No No No No No No No No No No No
the outcome(s) being measured?
7. Was the timeframe sufficient so that
one could reasonably expect to see an
No No No No No No No No No No No No
association between exposure and
outcome if it existed?
8. For exposures that can vary in amount
or level, did the study examine different
levels of the exposure as related to the
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
outcome (e.g., categories of exposure, or
exposure measured as continuous
variable)?
Int. J. Environ. Res. Public Health 2021, 18, 1552 10 of 15

Table 3. Cont.

Articles Dissertations
Medley, Abualrub, Wang, Nebiat, Wong, Bawafaa, Abdelhafiz, Alshahrani, Morsiani, Bormann, Despres, Mitterer,
Criteria
1995 2012 2012 2013 2013 2015 2016 2016 2017 2011 2011 2017
9. Were the exposure measures
(independent variables) clearly defined,
Yes Yes Yes Yes Yes Yes Yes NS No Yes Yes Yes
valid, reliable, and implemented
consistently across all study participants?
10. Was the exposure(s) assessed more
No No No No No No No No No No No No
than once over time?
11. Were the outcome measures
(dependent variables) clearly defined,
Yes Yes Yes Yes Yes Yes Yes NS No Yes Yes Yes
valid, reliable, and implemented
consistently across all study participants?
12. Were the outcome assessors blinded
Yes Yes NS Yes Yes Yes No NS Yes No No Yes
to the exposure status of participants?
13. Was loss to follow-up after baseline
NA NA NA NA NA NA NA NA NA NA NA NA
20% or less?
14. Were key potential confounding
variables measured and adjusted
statistically for their impact on the Yes Yes No No No No No Yes No No No Yes
relationship between exposure(s) and
outcome(s)?
Evaluation Fair Fair Fair Fair Fair Fair Fair Fair Fair Fair Fair Fair
Int. J. Environ. Res. Public Health 2021, 18, 1552 11 of 15

4. Discussion
In line with the findings of other studies in the literature [36,37], this review shows
that, regardless of the sample, the working environment, the country or the style adopted,
there is a significant correlation between leadership styles and job satisfaction. In fact, out
of 12 studies included, only three of them [24,25,33] did not show any correlation between
leadership style (only the transactional) and nurses’ job satisfaction. All the other studies
included found significant positive or negative correlations between the two variables
analysed.
Typical behaviours of servant leadership (humility, effective communication, and
commitment to the professional growth of employees) show strong relation between job
satisfaction and staff engagement [26]. Similarly, authentic leadership has shown, albeit
only in one study, positive correlation with job satisfaction. This is in accordance with the
findings of other studies [38,39].
Regarding the resonant leadership, it emerged that the ability to empower employees
has both direct and indirect influence on nurses’ job satisfaction. In this specific study,
the behaviour with the greatest impact and most appreciated by nursing staff was the
promotion and support of teamwork by the leader [27]. This underscores the importance of
ensuring staff feel part of a cohesive team, fostering an ethos of commitment and sharing
of common goals.
Our results also show that leaders who adopt a transformational style, promote
greater job satisfaction among nursing staff than those who adopt a transactional style.
This is in line with previous studies that suggested that an open bidirectional approach to
communication affects employees’ job satisfaction [40].
In most cases, transformational leaders spend time teaching and coaching nurses,
focus on developing and enhancing their strengths, provide advices for their professional
and personal development, treat subordinates as individuals, and listen to their concerns
and doubts. When this type of style is adopted, nurses are more efficient and put more
effort into achieving set goals. This finding parallels those of several other studies that have
also demonstrated that adoption of a transformational leadership style has the greatest
impact on healthcare system performance metrics [41,42].
The Multifactorial Leadership Model states that employees tend to be attracted by
leaders who show an enthusiastic and optimistic nature and who know how to make
long-term plans. The results of this literature review confirm the efficacy of this leadership
model.
Just as resonant leadership has been strongly associated with promoting empower-
ment, so too has transformational leadership. This has a significant role in furthering
employees’ sense of self-efficiency, which in turn helps promote job satisfaction.
Laissez-faire and passive-avoidant styles, in the management and coordination of
personnel, are the least effective leadership styles. This research highlights the significant
negative relationship between the professional satisfaction of staff and these leadership
styles. This confirms the findings of previous studies in the literature [15,43,44], despite
not all of them being conducted in the nursing context. The reason for this may be the fact
that in both of these styles, nurses are placed under pressure to achieve set goals, without
receiving guidance and practical or emotional support. These types of leadership styles do
not provide clear directions and therefore employees have to set their own goals, targets,
and decision-making processes. Staff may feel insecure or unattended to because they
do not have consistent manager attention. Just as the laissez-faire and passive-avoidant
styles are associated with a negative impact on employee performance measures, so too
does the adoption of the autocratic leadership approach. Too much direction or too little
communication from a manager, in fact, may negatively impact staff, leaving them feeling
unmotivated and neglected.
Our research reveals that, in some cases, the transactional leadership style has a
negative influence on nurses’ job satisfaction. This is line with other studies that found that
the transactional leadership style is the weakest predictor of professional satisfaction [45,46].
Int. J. Environ. Res. Public Health 2021, 18, 1552 12 of 15

On the contrary, in four of the selected studies there was a positive correlation between
transactional leadership style and job satisfaction [28–31]. This was associated with the
“Contingent Reward”, characterised by the opportunity to receive promotion and career
advancement in recognition of good performance or achieved goals.
One recent study showed that the Contingent Reward, subtype of the transactional
style, had characteristics common to the transformational style [47].
The reason for this could be found in the fact that professional motivation is connected
to the satisfaction of deep needs such as the need of having recognised personal qualities
and skills. This has a direct impact on the commitment to daily activities and on the intent
to stay within the organisation.
Our research shows how more than one leadership style has positive correlation with
job satisfaction. This met the authors’ aim of having the widest possible overview on the
topic, beyond the identification of the “perfect” leadership style.
Different leadership styles exist because people are, by nature, different in their traits,
characteristics, and communication abilities. It is therefore important for a leader to
understand when a particular style must be demonstrated or avoided.
Moreover, the results reveal that most studies analysed more than one leadership style
at the same time. This reflects the need to produce research which, by investigating on a
broad spectrum, allows light to be shed on a topic that is still largely empirically based and
with little robust scientific evidence. The fact that more than one style of leadership has
led to positive outcomes amongst healthcare staff, in terms of job satisfaction, is proof that
different cultures, contexts, and individuals require styles and approaches that vary over
time, according to circumstances.

5. Conclusions
In conclusion, looking at the relation found between leadership styles and job sat-
isfaction, we can say that nursing leaders are indispensable in creating positive work
environments that retain an empowered and motivated workforce. Positive and supportive
leadership styles can improve nurses’ job satisfaction, organisational commitment, and
intent to stay in their position while simultaneously reducing emotional exhaustion [48].
The studies analysed in this review have revealed that transformational leadership
has a significant positive correlation with levels of nursing job satisfaction. This means that
transformational leaders, through their inspiring and motivating behaviour, can induce
changes in the psychological states of members working within organisations.
Some of the studies analysed [27,34] have also shown that the adoption of resonant
and authentic leadership styles might be decisive in improving job satisfaction through the
development and strengthening of nurses’ sense of empowerment. These results suggest
that leaders who focus on transparency, self-awareness, and promotion of a “work ethic” are
able to empathise with their subordinates by recognising and understanding their concerns,
needs and desires. Nurses who experience this type of environment longitudinally develop
more confidence in their abilities and perform more effectively [49].
Furthermore, this study confirmed that perceived respect plays a key role in influenc-
ing nurses’ professional satisfaction.
Staff involvement during decision making gives them the opportunity to express
personal points of view and increases a sense of mutual esteem and teamwork within the
group. Institutions should promote the use of a two-way communication process and
highlight the need to strengthen mutual trust between leaders and staff.
The results of this study offer a starting point for researchers, professionals, and
leaders in the healthcare context to understand the benefits of adopting effective leadership
styles.
The skills required for personnel management and coordination by leaders and their
importance for creating successful organisations have been a literature topic for over 30
years. Despite this, much can still be investigated by future studies for the production of
quantitative data generalisable to a wider range of contexts. Understanding the ideal, rather
Int. J. Environ. Res. Public Health 2021, 18, 1552 13 of 15

than perfect, characteristics of an effective leader should guide the process of recruiting
and training personnel with management and coordination roles.
Within healthcare organisations, leadership plays a key role in providing effective and
efficient care and results in positive outcomes for professionals, patients, and the work
environment. It is therefore necessary to identify and fill the current gaps in leadership
skills, in order to positively affect health professionals’ job satisfaction and subsequently
improve healthcare quality indicators. Understanding the different effects of leadership
styles allows recognition of the ways in which they impact employees, and secondly, it
allows greater organisational achievement through discerning when a particular leadership
style benefits or diminishes organisational goals.
The systematic review relied on a relatively limited number of eligible studies. More-
over, none of the studies were of good quality. Indeed, all of them were cross-sectional
studies and therefore susceptible to bias because of the study design. This was reflected in
the results of the methodological assessment, which led to the labelling of all the studies
as “FAIR”. However, although no studies were rated as “GOOD”, even “POOR” studies
were not found. Moreover, a limit that applies to our 12 studies, considered as a whole,
has been that the criteria used to define leadership styles and the tools used to measure
the level of nurses’ job satisfaction (although for some studies that are partly overlap-
ping) are heterogeneous among the 12 studies. This did not allow to perform a rigorous
meta-analysis.
Another bias to consider is the potential publication bias. It could be possible that
studies with negative findings have not been published and that the correlations between
leadership style and job satisfaction have been overemphasised. However, since the authors
considered not only studies published in peer reviewed journals, but also dissertations,
the potential publication bias may have been balanced. A thorough process of quality
appraisal, based on the independent review by two authors and the use of previously
validated quality appraisal tools, aided in ensuring that results were given appropriate
consideration and weight and assisted the authors to determine where high quality research
may have been lacking.

Author Contributions: Conceptualization and methodology: M.L.S., G.D., M.R.C.; Data collection:
M.R.C., E.C.; Formal analysis and writing—original draft preparation: M.R.C., E.C.; Writing—review
and editing: M.R.C., M.L.S., A.D.P.; supervision: M.L.S., C.G., W.R.; All authors have read and agreed
to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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