JMIR Publications

ABSTRACT

Background:

Effective leadership among nurses is essential for improving patient outcomes, fostering interprofessional collaboration, and ensuring high-quality healthcare delivery. With the expanding scope of nursing practice, both clinical and administrative leadership have become critical competencies across diverse healthcare settings.

Objective:

This systematic review aimed to identify and evaluate strategies that promote administrative and clinical leadership among nurses, examining their effectiveness across various professional and geographical contexts.

Methods:

Following the PRISMA guidelines, a comprehensive literature search was conducted across five databases, PubMed, Scopus, Web of Science, Cochrane Library, and CINAHL. Peer-reviewed studies published between January 2000 and March 2025 were eligible if they employed quantitative or mixed-method designs, focused on registered nurses or nursing students, and assessed interventions targeting leadership development. Studies were screened, appraised using JBI and MMAT tools, and synthesized narratively based on intervention type, leadership domain, and outcomes.

Results:

Results 3.1 Study Selection Summary The initial literature search retrieved 2,192 records from five major electronic databases. After removing 978 duplicates, a total of 1,214 titles and abstracts were screened. Of these, 56 full-text articles were assessed for eligibility based on predefined inclusion and exclusion criteria. Following the full-text review, 32 articles were excluded due to reasons such as language (n = 8), inappropriate study design (n = 17), or wrong outcome focus (n = 8). Ultimately, 23 studies met the inclusion criteria and were incorporated into this systematic review. These studies represent diverse geographic settings, research methodologies, and intervention strategies relevant to both clinical and administrative nursing leadership. A PRISMA flow diagram summarizing the study selection process is presented in Figure 1. 3.2 Characteristics of Included Studies The 23 included studies represented diverse global contexts, with the majority conducted in Asia; including Taiwan, China, Saudi Arabia, Pakistan, and Iran. Additional studies originated from Africa (Egypt, South Africa), North America (Canada), and Europe (Turkey), while several systematic or scoping reviews incorporated multi-country analyses or global data. A wide range of study designs was represented: 6 randomized controlled trials (RCTs), 8 quasi-experimental studies, 4 cross-sectional or survey-based designs, and 5 systematic or scoping reviews. The sample populations included nursing students, clinical nurses, head nurses, and nurse managers, spanning junior to senior leadership levels. Interventions were evaluated in varied settings such as tertiary teaching hospitals, general hospitals, outpatient centers, and academic institutions. The majority of studies (20 out of 23) were published after 2018, reflecting current practices and contemporary leadership theories. This diversity enhances the generalizability of findings across healthcare systems, from public to private sectors, and from academic to clinical environments. A detailed account of each study’s methodology, intervention, and outcome measures is available in Appendix B. 3.3 Intervention Types The interventions implemented across the reviewed studies were varied but broadly grouped into five categories. Most studies employed structured leadership development programs, while others emphasized mentorship, empowerment, relational leadership styles, and emotional intelligence. Structured leadership development programs formed the backbone of many interventions. For instance, Omer et al. [12], introduced a 16-week competency-based leadership training program at King Abdulaziz Medical City, targeting nurse managers with modules in evidence-based practice, communication, and technology use. Similarly, Ming et al. [13], conducted a multi-tiered intervention in Taiwan that combined classroom instruction, hospital internships, and managerial mentorship for high-performing young nurses. This program led to significant gains in self-reported management function (+1.14, p < .001) and improved team behavior scores. Concurrently, Chang et al. [14], incorporated leadership education into nine core curriculum courses for master's-level nursing students in Taiwan. Their program showed a mean increase of 8.94 points in leadership competence scores (p < .01), underlining the value of curriculum-integrated interventions. Mentorship and coaching were highlighted in Shen and Tucker’s [15], qualitative exploration of the Midwest Nursing Research Society Leadership Academy. Their study emphasized the effectiveness of structured mentor-mentee pairings in developing leadership confidence, identity, and long-term capability, especially in early-career nurse leaders. Empowerment-based interventions were also prominent. MacPhee et al. [16] and Dahinten et al. [17] evaluated the Nursing Leadership Institute in Canada, focusing on how leadership training affected leader-empowering behaviors and their influence on staff empowerment and organizational commitment. Both studies used validated scales such as the Conditions for Work Effectiveness Questionnaire-II (CWEQ-II) and found that empowering behaviors were significantly associated with improved staff outcomes and mediated commitment pathways. Emotional intelligence (EI) and relational training approaches were exemplified by Hamed et al. [18], who implemented a situational leadership and EI development program in Egypt. The study reported remarkable improvements: high EI among head nurses increased from 22.2% pre-intervention to 84.4% post-intervention, while managerial competency rose from 53.3% to 91.1%. Finally, shared or authentic leadership models were evaluated in several studies linked transformational leadership with enhanced clinical leadership behaviors and fewer adverse patient outcomes via workplace empowerment mechanisms [19 - 22]. Wong and Laschinger [20] demonstrated that authentic leadership significantly enhanced job satisfaction and performance through structural empowerment, while Kim and Han [23] established empowerment as a full mediator between authentic leadership and nursing performance. 3.4 Leadership Domains Targeted The reviewed interventions both targeted administrative and clinical leadership areas, although differently prioritized according to participant roles and organizational aims. Administrative leadership comprising skills like strategic planning, resource deployment, and coordination of departments featured as a key area of interest in middle and senior nurse manager studies. Aqtash et al. [24], for example, compared self-reported enhanced managerial proficiency after leadership development based on the SQUIRES framework, whereas Omer [12] and Emam et al. [25], prioritized administrative skills like financial management, evidence-based practice, and monitoring performance. Conversely, clinical leadership featured as the area of concern for interventions on decision-making at the point-of-care level, patient advocacy as well as team coordination. Ming et al. [13], evaluated clinical skills like management function and team behavior in young elite nurses, and Boamah [21], proved the effect of transformational leadership by frontline nurses on clinical performance as well as workplace empowerment. Some of the interventions by Hamed et al. [18] and Mushtaq et al. [26] targeted both areas at the same time through interventions on situational leadership, emotional intelligence, and staff motivation. Generally speaking, the review points toward the variability of the leadership skills required in nursing and emphasizes the benefits of holistic interventions developing both administrative and clinical abilities as part of a single approach. 3.5 Outcome Measures Reported These studies employed a variety of outcome measurements in the assessment of the effectiveness of leadership interventions. The most frequent measurement employed were self-reported competency and involved elements of leadership knowledge, decision-making self-confidence, emotional intelligence and managerial skill perception. These were generally measured through pre- and post-intervention questionnaires or established tools like the Nurse Manager Competency Instrument (NMCI), as in the case of research by Omer [12] and Hamed et al. [18]. Some studies also set out to measure observed outcomes, usually through feedback from peers or supervisors in a measurement of leadership behavior. In some examples, Ming et al. [13] and Chen [11] used a combined approach of self-assessment and manager-rated team behavior as a measure of participant improvement. Organizational markers of patient safety climate, burnout, job satisfaction levels, and turnover rates were also reported in several studies. Statistically significant decreases in emotional exhaustion and increases in personal accomplishment were reported by Xie et al. [27] for nurses after a patient safety leadership intervention. Likewise, authentic leadership correlated with enhanced nursing performance and job satisfaction by Kim and Han [23], and empowerment acted as a mediator. Among the most frequently used measurement instruments were the CWEQ-II (Conditions of Work Effectiveness Questionnaire) [11,16,17,20,22,23,24], the Maslach Burnout Inventory (MBI) [19,21], and structured job satisfaction surveys [8]. Seven out of the 23 included studies used validated leadership competence or empowerment scales, enhancing the reliability and comparability of findings across diverse contexts [13,14,12,24,2,8,27]. 3.6 Effectiveness of Interventions The studies reviewed documented general positive effects of leadership interventions in leadership skills, staff motivation, and organizational performance. Leadership skills and knowledge always enhanced upon systematic instruction. Ming et al. [13], for example, noted a statistically significant difference in scores on the management function (Δ = +1.14, p < .001) and long-term improvement in team behavior in high-performing young nurses. Chang et al. [14], also noted an 8.94-point improvement in leadership competency (p < .01) upon integrating modules on leadership in academic courses. Empowerment manifested as a common thread, and multiple studies indicated it as a mediating or intervening effect of good leadership. Wong and Laschinger [20] and Kim and Han [23] confirmed the construct of authentic leadership as having a positive effect on structural empowerment, which subsequently affects increased job satisfaction and performance. Empowerment also acted as a mediator between leadership development and commitment in research conducted by MacPhee et al. [16] and Dahinten et al. [17], proving important in converting leadership behavior into staff commitment. At an organizational level, positive changes were noted in patient safety behavior, staff morale, and burnout reduction. Xie et al. [27], found improved leadership behavior in head nurses and reduced emotional exhaustion in clinical nurses from participation in a safety leadership development program. Hamed et al. [18] also identified significant improvement in managerial competency through emotional intelligence training and inferred wider workforce benefits. Critically, some studies showed long-term maintenance of gains. Emam et al. [25] found continued leadership knowledge and self-perceived competency at three-month follow-up after the intervention and Ming et al. [13] showed maintained team behavior change at the same time interval. These results collectively demonstrate lasting effects of leadership development programs when well-designed and embedded in context. 3.7 Ethical Approval This systematic review did not involve human participants and thus did not require ethical approval.

Conclusions:

Conclusion This systematic review set out to evaluate and synthesize the most effective strategies for promoting administrative and clinical leadership among nurses across global healthcare contexts. The review was guided by the recognition that nurses play a dual role, not only as frontline caregivers but also as pivotal organizational leaders tasked with improving patient outcomes, optimizing team dynamics, and ensuring strategic alignment with broader health system goals. As the complexity of healthcare delivery intensifies, so too does the demand for competent, visionary nursing leaders who are adept in both clinical and administrative capacities. Across the 23 studies included in this review, it is evident that leadership development interventions yield consistently positive outcomes. Structured leadership development programs emerged as the most commonly employed and most effective intervention type. Empowerment models also enhanced leadership performance through psychological and structural empowerment in emerging and established nurse leaders This review also points out a number of gaps and weaknesses in the existing literature despite these strengths. Most of studies used self-reported outcomes and so were limited by a lack of objectivity in results. Furthermore, few used randomized controlled trials and even fewer used long-term follow-up measurements. These methodological failures highlight a requirement for better research in demonstrating causality and sustainability of leadership development effects. At the educational and policy levels, curriculum planners should make certain that emotional intelligence-related leadership competencies, communication skills, ethical decision making and strategic planning are infused in undergraduate and postgraduate nursing education. The research agenda must also evolve to support the growing demand for evidence-informed leadership development. Future studies should prioritize the use of RCTs, mixed-methods designs, and longitudinal tracking to assess both immediate and sustained impacts of leadership interventions. This review reaffirms that effective nursing leadership, both clinical and administrative, is essential to achieving high-quality, safe, and equitable healthcare. Leadership development programs that are theory-driven, context-sensitive, and skill-integrated hold significant promise in cultivating the next generation of nurse leaders. By embedding leadership training into the educational continuum, supporting mentorship and empowerment in practice, and advancing a rigorous research agenda, stakeholders across nursing education, practice, and policy can collectively build resilient, competent, and visionary nursing leadership for the future.