Poels et al.

BMC Health Services Research (2020) 20:1009

https://doi.org/10.1186/s12913-020-05854-7

RESEARCH ARTICLE Open Access

Leadership styles and leadership outcomes

in nursing homes: a cross-sectional analysis
Joris Poels1* , Marc Verschueren1,2, Koen Milisen1,3 and Ellen Vlaeyen1

Abstract
Background: Although leadership is considered as a key factor in health care, leadership styles and outcomes in
nursing homes often remain a black box. Therefore, this study explored leadership styles and leadership outcomes
of head nurses and directors of nursing (DoN) in nursing homes based on well-defined leadership concepts.
Methods: A multicenter cross-sectional analysis was conducted on baseline data of an ongoing cohort study
comprising a convenience sample of nursing home staff (n = 302). Leadership styles and leadership outcomes of
head nurses and DoN were measured through the rater form of the Multifactor Leadership Questionnaire 5X (MLQ-
5X). Based on the Full Range of Leadership Model, the MLQ-5X visualizes transformational (relation and change
focused), transactional (task-focused) and passive-avoidant (absence of leadership) leadership styles. Scores of head
nurses and DoN for leadership styles and outcomes were compared with European Reference Scores (ERS) using
two-sided one-sample t-tests.
Results: Compared with ERS, head nurses and DoN scored significantly lower (p < 0.001) on transformational and
transactional leadership styles and significantly higher (p < 0.001) on passive-avoidant leadership styles. All
leadership outcomes were significantly lower (p < 0.001) for head nurses. Similar results, however not statistically
significant, were found concerning leadership outcomes of DoN.
Conclusions: Results indicate that passive-avoidant leadership styles are excessively present in contrast to
transformational leadership styles in nursing homes. This highlights an urgent need to invest in leadership
development. Therefore, future research should focus on interventions for the development of transformational
leadership.
Keywords: Leadership, Residential care facilities, Nursing home, Care manager, Nurse, Director of nursing

Background complex conditions and are in need of more assistance

Worldwide demographic evolutions affect the [4, 5]. Secondly, poor work organization, time pressure,
organization of health care. Especially nursing homes high workload, staff shortages and turnover are potential
face daunting challenges to meet present and future care threats to quality of care and patient safety [6–9]. Previ-
needs [1, 2]. Firstly, individuals consider a nursing home ous research showed high annualized turnover rates for
as a last resort and therefore prefer to live as long as certified nurse assistants (74.5%), registered nurses
possible in their own home [3]. Consequently, most resi- (56.1%) and licensed practical nurses (51.0%) in nursing
dents admitted to a nursing home suffer from multiple homes [10]. The American Association of Colleges of
Nursing predicts by 2025, without appropriate interven-
* Correspondence: [email protected] tion strategies, a shortage of approximately 260,000 reg-
1
Department of Public Health and Primary Care, Academic Centre for istered nurses in the United States [11]. These shortages
Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35, 4th floor, P.B. 7001,
3000 Leuven, Belgium could negatively affect the number of staff available in
Full list of author information is available at the end of the article nursing homes. Moreover, the Institute of Medicine
© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
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Poels et al. BMC Health Services Research (2020) 20:1009 Page 2 of 10

reports financial and work environment related chal- refers to a leader actively monitoring the work of fol-
lenges, such as low wages and job dissatisfaction, in the lowers so that, in case of errors, corrective actions
recruitment and retention of direct-care workers [12]. In can be undertaken. Transactional leadership will often
addition, both intention to leave and to stay among result in expected outcomes [19]. Finally, the third
nurses are associated with leadership practices [13]. In leadership style, passive-avoidant leadership, consists
general, literature increasingly describes leadership as a of two components: 1) passive management-by-
key factor in solving challenges in health care. North- exception, reflecting avoidance of leadership, and 2)
ouse (2013) defines leadership as ‘a process whereby an laissez-faire, which means absence of leadership [15,
individual influences a group of people in order to 20]. In addition to measuring leadership styles, the
achieve a common goal’. Its contribution is considered FRLM provides a questionnaire (the MLQ-5X) that
equally important in enhancing the quality of care as in also includes nine questions on three outcomes of
a complex and high risk environment like aviation [14, leadership behavior. The first leadership outcome,
15]. For example, when staff perceives leadership as extra effort, measures how often followers perceive
good it positively influences their retention and job satis- their leader as someone that motivates others to do
faction [13, 16]. more, heightens desires to succeed and increases will-
Leaders can exhibit a variety of leadership styles, ingness to try harder. The second, effectiveness, re-
characterized by behavioral dimensions. Task-oriented flects how successful a leader interacts at different
leadership focuses on coordinating and assigning work levels of the organization, representing a group to
to followers. Change-oriented leadership aims at the higher authorities and meeting others’ job-related
identification, envisioning and managing of change on needs. The third, satisfaction, measures whether fol-
team level. Relation-oriented leadership comprises of lowers are satisfied with their leader’s working
team development and support [17, 18]. In particular, methods [21].
the Full Range of Leadership Model (FRLM) of Avolio The most recommended style of relation-oriented
and Bass provides a broad perspective on leadership leadership, included in the FRLM, is transformational
styles. The first leadership style, transformational leadership [17]. Focusing on the development and imple-
leadership, motivates followers to do more than what mentation of change, this leadership style motivates fol-
is expected of them. This leadership style aims to in- lowers to perform beyond what is expected of them [19,
crease the levels of motivation and morality among 22]. Literature suggests a link between transformational
followers, by invoking idealized influence, individual- leadership and several factors. In terms of workforce
ized consideration, inspirational motivation and. Intel- outcomes, transformational leadership is associated with
lectual stimulation. Firstly, Idealized influence increased staff-wellbeing, higher job satisfaction, de-
comprises two subcomponents: 1) Idealized influence creased intention to leave and decreased burn-out rate
attributed describes the extent to which a leader [23–25]. One study shows a direct negative relation be-
works on trusting relationships, whereas 2) idealized tween burn-out and transformational leadership (β = −
influence behavior focuses on the degree to which a 0.19, p < 0.01) [26]. This leadership style also positively
leader acts with integrity and works on a collective correlates with patient outcomes such as higher patient
mission. Secondly, individual consideration measures satisfaction, higher quality of care, lower mortality and
the extent to which a leader supports and coaches less medication errors [27, 28]. Lastly, transformational
group members. Thirdly, inspirational motivation is leadership relates to organizational outcomes such as in-
measured to gain insight in the extent to which a creased innovation capacity [29]. Although the potential
leader motivates followers with an inspiring vision. of transformational leadership in health care is well de-
Fourthly, intellectual stimulation measures the degree scribed, the empiric literature on leadership styles in
that a leader appeals on the abilities of employees to nursing homes often remains conceptually unclear.
identify problems and to approach these problems Apart from a few studies that suggest the importance of
creatively. Transformational leadership will often re- relation-oriented leadership, the leadership styles mea-
sult in performance that surpasses the expected out- sured in nursing homes frequently are a black box to be
comes [19]. The second leadership style, transactional unravelled [30, 31]. Given the need of transformational
leadership, emphasizes the exchange relationship be- leadership as an indispensable element in developing,
tween leader and follower; both encouraged to meet implementing and sustaining the crucial changes that
their own needs. Transactional leadership has two health care needs to make to improve quality of care
components: 1) contingent reward refers to clarifying and patient safety, this study aims to explore leadership
roles and tasks, and providing followers with material styles in nursing homes based on well-described con-
or psychological rewards contingent on the fulfillment cepts [32, 33]. In addition, this study will also explore
of obligations; 2) active management by exception outcomes of the present leadership styles.
Poels et al. BMC Health Services Research (2020) 20:1009 Page 3 of 10

Methods staff recruitment, handling staff conflicts, monitoring of

This study was reported following the STROBE guide- care quality and representation to other organizations
lines for observational studies [34]. [37]. Head nurses were rated by at least five staff mem-
bers working on their ward. DoN were rated by all head
Sample, setting and design nurses in the respective nursing home. Some staff re-
A cross-sectional analysis was conducted on baseline ported to work throughout the entire nursing home and
data of an ongoing cohort study in 2015 comprising a did not solely belong to one ward. They report directly
convenience sample of staff in six nursing homes in to the DoN and therefore rated the DoN as their direct
Belgium. Nursing homes were included if the managing supervisor. Participants had to master Dutch and partici-
board agreed to participate, but were excluded if they pate voluntarily.
already participated in another study. Participating staff
had to speak and read Dutch. The Medical Ethics Com- Measures
mittee of the University Hospitals Leuven approved this A validated Dutch version of the Multifactor Leadership
study with EC number S52526. All participating staff Questionnaire 5X (MLQ-5X) form was used to measure
provided informed consent by voluntarily completing leadership styles and outcomes of head nurses and DoN
the data collection. [21]. The MLQ-5X comprises 45 items divided into nine
subscales to capture a broad range of leadership behav-
Procedure iors. Items are scored using a five-point Likert scale with
In every nursing home, a moment was scheduled in responses that range from “never” (0) to “frequently, if
which staff completed a survey, rating leadership styles not always” [4]. They reflect the degree to which certain
of their direct supervisor. Two levels of leadership were leadership behaviors are present and are based on the
examined (Fig. 1). The first level involved the leadership components of the Full Range of Leadership Model
of head nurses, who plan, coordinate, monitor, control (FRLM) of Avolio and Bass [21]. The FRLM is a well-
and adjust the activities on their ward in order to ensure established model, supported by the accumulation of
that staff can deliver individualized care in optimal con- evidence on its validity throughout 30 years [38]. Trans-
ditions [35, 36]. The second level involved the leadership formational, transactional and passive avoidant leader-
of directors of nursing (DoN), who are continuously bal- ship styles, respectively ranked from higher to lower
ancing between clinical leadership and managerial tar- effectivity, are included in the model [19]. Previous re-
gets. DoN have a complex role in budgets and finances, search confirmed adequate construct and predictive

Fig. 1 Rating of leadership styles and leadership outcomes by staff in nursing home: direction of rating leadership styles and
leadership outcomes
Poels et al. BMC Health Services Research (2020) 20:1009 Page 4 of 10

validity of the MLQ-5X in that it satisfies the model fit attributed, idealized influence behavior, inspirational
requirement. In addition, based on factorial invariance motivation, intellectual stimulation and individual con-
tests to study the model’s consistency, previous research sideration. Staff rates contingent reward, being part of
confirmed the reliability of the MLQ-5X in that it mea- transactional leadership, also significantly lower (p <
sures the same constructs across multiple groups [39]. 0.001) in head nurses, whereas passive-avoidant leader-
To interpret the acquired data the MLQ-5X manual pro- ship scores are significantly higher (p < 0.001).
vides a scoring key that indicates which scale items Staff scores head nurses significantly lower on all lead-
should be grouped. Transformational, transactional and ership outcomes (p < 0.001), compared with the ERS
passive avoidant leadership are respectively measured by (see Table 2). Intercorrelations of MLQ-subscales are
twenty, eight and eight items. For leadership outcomes, consistent with findings in the European normative
which can be considered as results of leadership behav- sample.
ior, extra effort, effectiveness and satisfaction are re-
spectively measured by three, four and two items [21]. Directors of nursing
Because of copyright stipulations, more detailed infor- Twenty head nurses and 38 other staff rated leadership
mation about the questionnaire, scoring key and which styles and outcomes of 9 DoN (see Fig. 1). Respondents
items are related to which leadership style is provided in are mainly female (93.1%), with a mean age of 42.2 year
the MLQ-5X Manual [21]. (±9.3y) and work on average 11.8 years (±9.9y) in the
current nursing home. They work as head nurse (34.5%),
Analysis night nurse-assistant (41.4%), night nurse (15.5%) and
Analysis were performed using SPSS version 22.0 (IBM physiotherapist (8.6%) with a mean number of 28.3 h (±
SPSS, Armonk, NY: IBM Corp.). Analysis were per- 10.6 h) per week. Table 3 shows that, compared with the
formed for leadership styles of head nurses and DoN in ERS, DoN score significantly lower on idealized influ-
the overall sample. For each component of the FRLM ence attributed and individual consideration (p < 0.001)
means were calculated. Using a two-sided one-sample t- whereas passive-avoidant leadership scores are signifi-
test, means were compared with the European Reference cantly higher (p < 0.001).
Scores (ERS), which are normative scores for leadership No significant results are found in outcomes of leader-
styles and outcomes based on cross-cultural research ship in DoN (see Table 4). Intercorrelations of MLQ-
[21]. Scores of head nurses and DoN were compared to subscales are consistent with findings in the European
norm scores for their respective levels, based on norma- normative sample.
tive samples of respectively 3061 and 1222 respondents
with a high executive or senior staff function [21]. To Reliability of the MLQ-5X
correct for multiple testing, a Bonferroni-adjustment Cronbach’s alpha was used to test the reliability of the
was used, setting the significance threshold at α = 0.002 MLQ-5X subscales in both raters of head nurses and
[40]. A Pearson product-moment correlation coefficient DoN (see Tables 1, 2, 3, and 4). With regard to raters of
was calculated for each FRLM-component. Cronbach’s head nurses, internal consistency of scale items is poor
alpha was used to test the internal consistency of the for idealized influence attributed (α = 0.48) and passive
MLQ-5X subscales, considering a value of ≥0.80 as good management by exception (α = 0.54). In raters of DoN
and < 0.60 as poor [41]. internal consistency is poor for idealized influence (α =
0.42), active (α = 0.06) and passive management by ex-
Results ception (α = 0.56). Cronbach’s alpha enhances only in
Head nurses the subscale idealized influence attributed if the item
In total 242 staff received the questionnaires on leader- that considers transcending self-interest was deleted in
ship styles and outcomes of 22 head nurses of which 235 both head nurses (α = 0.77) and DoN (α = 0.73).
completed these questions (response rate: 97.1%). Re-
spondents are mainly female (91.5%), with a mean age of Discussion
38.1 years (±12.1y) and work on average 10 years in the To the best of our knowledge, this is the first study that
current nursing home (±10.1y). They work as nurse- quantitatively investigates and maps leadership styles
assistant (63.0%), nurse (24.7%), physiotherapist (6.8%), and leadership outcomes of head nurses and directors of
occupational therapist (5.1%) and general practitioner nursing (DoN) in nursing homes. Compared with the
(0.4%), with a mean number of 28.3 h (±10.6 h) per European Reference Scores (ERS), head nurses and DoN
week. Table 1 shows that, compared with the European score significantly lower (p < 0.001) on components of
Reference Scores (ERS), staff rates their direct leaders transformational and transactional leadership, but score
significantly lower (p < 0.001) on four out of five compo- significantly higher (p < 0.001) on passive-avoidant lead-
nents of transformational leadership: idealized influence ership. In addition, head nurses score significantly lower
Table 1 Leadership styles of head nurses in nursing homes
Head nurses Mean (±SD) ERS Sample Correlations Cronbach’s
(CI 99.8%) alpha
(1) (2) (3) (4) (5) (6) (7) (8)
Transformational
(1) Idealized influence: attributed 2.17< (±0.67) 2.72 234 0.48
(2.04–2.31)
(2) Idealized influence: behavior 2.62 (±0.72) 2.69 233 0.58** 0.74
(2.48–2.77)
(3) Inspirational motivation 2.62< (±0.79) 2.83 233 0.63** 0.80** 0.86
(2.45–2.78)
(4) Intellectual stimulation 2.56< (±0.69) 2.82 234 0.62** 0.77** 0.77** 0.78
Poels et al. BMC Health Services Research

(2.42–2.70)
(5) Individual consideration 2.42< (±0.76) 2.66 234 0.61** 0.65** 0.64** 0.65** 0.65
(2.27–2.58)
Transactional
(6) Contingent Reward 2.57< (±0.78) 2.77 235 0.59** 0.79** 0.79** 0.76* 0.68** 0.81
(2020) 20:1009

(2.41–2.73)
(7) Management by exception: active 2.30 (±0.68) 2.33 232 0.37** 0.33** 0.29** 0.25** 0.27** 0.30** 0.62
(2.16–2.44)
Passive/avoidant
(8) Management by exception: passive 1.29> (±0.71) 1.10 233 −0.25** − 0.34** − 0.38** − 0.36** −0.23** − 0.31** 0.05 0.54
(1.15–1.44)
(9) Laissez-faire 1.13> (±0.78) 0.79 234 −0.25** −0.44** − 0.46** −0.44* − 0.39** −0.39** 0.07 0.65** 0.74
(0.97–1.29)
Scores on subscales (1–9) have an available range between 0 and 4; CI Confidence Interval, ERS European Reference Scores; <: significant lower (p < 0.002) than ERS; >: significant higher (p < 0.002) than ERS;
*correlation significant (p < 0.05); **correlation significant (p < 0.01)
Page 5 of 10
Poels et al. BMC Health Services Research (2020) 20:1009 Page 6 of 10

Table 2 Leadership outcomes of head nurses in nursing homes

Head nurses Mean (±SD) ERS Sample Correlations Cronbach’s
(CI 99.8%) alpha
(1) (2)
(1) Extra Effort 2.43< (±0.79) 2.75 231 0.79
(2.27–2.59)
(2) Effectiveness 2.64< (±0.72) 3.01 232 0.77** 0.84
(2.49–2.79)
(3) Satisfaction 2.67< (±0.83) 2.94 231 0.75** 0.83** 0.72
(2.50–2.84)
Scores on subscales (1–3) have an available range between 0 and 4; CI Confidence Interval; ERS European Reference Scores; <: significant lower (p < 0.002) than
ERS; >: significant higher (p < 0.002) than ERS; *correlation significant (p < 0.05); **correlation significant (p < 0.01)

than ERS on all leadership outcomes (p < 0.001). Similar nursing homes are confronted with a conflict between
results, however not statistically significant, are found management targets and optimal care delivery. In order
concerning leadership outcomes of DoN. Previous re- to cope with these contradictory circumstances they may
search on leadership styles in nursing homes found that, use avoidance as a survival strategy [50]. Consequently,
based on the Bonoma-Slevin leadership model, an auto- staff may perceive absent, passive-avoidant leadership.
crat style was used by 25% of DoN. An autocrat leader However, in previous research leadership was described
does not involve, nor informs employees about decisions as flexible, creative and supportive by staff in high-
[42]. In addition, results showed that a consensus leader- performing nursing homes and as out-of-touch in low-
ship style, that involves employees and encourages team performing nursing homes [30]. A recent systematic re-
decision making, was used by only 30% of DoN [42, 43]. view confirms the negative influence of passive-avoidant
Given the potential influences on care quality and pa- leadership styles such as management by exception and
tient safety, our results, showing low scores on trans- laissez-faire leadership on staff satisfaction with work,
formational leadership styles and high scores on passive- job and their leaders, staff health and wellbeing, staff
avoidant leadership styles, are alarming. Several aspects productivity and effectiveness, highlighting the import-
may contribute to our study results. First, nursing lead- ance of the findings in our study [13].
ership often seems to be conflated with administrative
positions. Therefore, head nurses may not be able to Strengths of the study
lead staff if their available time is filled with administra- This study seems unique, because it quantitatively inves-
tive tasks that hinder a visible presence on their wards. tigates and maps leadership styles and leadership out-
Consequently, the low scores on leadership outcomes comes on different levels in nursing homes. Second,
may reflect some dissatisfaction of staff with the current previous research in nursing homes concerning leader-
‘absence’ and ‘avoidance’ of leadership [44]. Although ship is often limited to the measurement of transform-
leadership styles may be context dependent, previous re- ational leadership styles. However, this study includes all
search investigating characteristics of highly rated lead- leadership styles of the FRLM, enabling a broader
ership confirmed non-avoidant and non-passive insight. Third, the extension of the MLQ-5X concerning
behaviors such as coaching, closely monitoring of work leadership outcomes is included, providing insight in re-
and giving direct feedback (i.e. being visible) as crucial in sults of leadership styles. Fourth, a stringent Bonferroni-
nursing home leaders [45]. Furthermore, this is also con- adjustment is applied to the alpha-level (p < 0.002) to
sistent with previous findings in hospitals, a leader that minimize the risk of reporting a statistically significant
is perceived as ‘good’ by staff may be one that is visible difference while this is actually not present. Fifth, self-
[46]. Similarly, to effectively provide guidance to the ratings are often used to measure leadership. However,
nursing home managing board, DoN need to remain considering the potential influence of leadership on staff
closely in contact with staff. Their recommendations performance, in our study, leaders are rated by their staff
should include issues and perspectives of staff (e.g. head to avoid self-serving bias through self-ratings [13, 51].
nurses) ‘on the front line’ [47]. Second, there could be a
discrepancy between the expected leadership and the Limitations of the study
perceived leadership of staff. Expectations of leadership Some limitations warrant further notice. First, the avail-
are influenced by various factors, like for example educa- able European Reference Scores (ERS) for the MLQ-5X
tion. Nurse-assistants and head nurses often have a dif- are not specific for the context of health care. They were
ferent educational background possibly influencing their derived from higher executive levels of leadership, limit-
conceptions of leadership [48, 49]. Third, due to rising ing their suitability for use in nursing homes [21].
demands and limited resources, DoN and head nurses in Therefore, the comparison of scores between a group of
Table 3 Leadership styles of directors of nursing in nursing homes
Directors of Nursing Mean (±SD) ERS Sample Correlations Cronbach’s
(CI 99.8%) alpha
(1) (2) (3) (4) (5) (6) (7) (8)
Transformational
(1) Idealized influence: attributed 2.36< (±0.62) 2.77 57 0.42
(2.10–2.63)
(2) Idealized influence: behavior 2.77 (±0.65) 2.73 58 0.59** 0.74
(2.49–3.04)
(3) Inspirational motivation 2.85 (±0.66) 2.68 57 0.67** 0.76** 0.86
(2.57–3.14)
(4) Intellectual stimulation 2.62 (±0.58) 2.74 56 0.49** 0.68** 0.66** 0.73
Poels et al. BMC Health Services Research

(2.37–2.87)
(5) Individual consideration 2.31< (±0.73) 2.75 57 0.66** 0.50** 0.58** 0.48** 0.60
(1.99–2.62)
Transactional
(6) Contingent Reward 2.77 (±0.69) 2.90 58 0.66 0.64** 0.71** 0.71** 0.55** 0.75
(2020) 20:1009

(2.48–3.06)
(7) Management by exception: active 2.30 (±0.57) 2.31 58 0.37** 0.39** 0.26 0.26 0.15 0.32* 0.06
(2.05–2.54)
Passive/avoidant
(8) Management by exception: passive 1.56> (±0.66) 1.16 57 −0.31* −0.23 −0.39** −0.31* −0.36** −0.39** 0.19 0.56
(1.28–1.84)
(9) Laissez-faire 1.20> (±0.77) 0.85 58 −0.45** −0.50** − 0.56** −0.43** − 0.48** −0.53** 0.02 0.55** 0.75
(0.87–1.53)
Scores on subscales (1–9) have an available range between 0 and 4; CI Confidence Interval, ERS European Reference Scores; <: significant lower (p < 0.002) than ERS; >: significant higher (p < 0.002) than ERS;
*correlation significant (p < 0.05); **correlation significant (p < 0.01)
Page 7 of 10
Poels et al. BMC Health Services Research (2020) 20:1009 Page 8 of 10

Table 4 Leadership outcomes of directors of nursing in nursing homes

Directors of Mean (±SD) ERS Sample Correlations Cronbach’s
Nursing (CI 99.8%) alpha
(1) (2)
(1) Extra Effort 2.54 (±0.74) 2.66 56 0.73
(2.22–2.86)
(2) Effectiveness 2.78 (±0.63) 2.96 56 0.74** 0.76
(2.51–3.05)
(3) Satisfaction 2.86 (±0.74) 2.92 57 0.69** 0.83** 0.86
(2.54–3.18)
Scores on subscales (1–3) have an available range between 0 and 4; CI Confidence Interval, ERS European Reference Scores; <: significant lower (p < 0.002) than
ERS; >: significant higher (p < 0.002) than ERS; *correlation significant (p < 0.05); **correlation significant (p < 0.01)

executives (i.e. the ERS) and head nurses in nursing unlikely to meet the complex demands in this context.
homes should be interpreted with caution. European The well-known paradox of meeting more needs with
Reference Scores for leadership in health care settings fewer resources makes the necessity for effective inter-
could support a more accurate comparison. Second, ventions on leadership and leadership development in
compared with the sample size for raters of head nurses, nursing homes undeniable. Effective interventions spe-
the small sample size for raters of DoN may limit the cific to nursing homes currently seem to be lacking,
generalizability of the results. However, this likely re- however the participation of head nurses and DoN in
flects the organizational proportions of functions in existing programs on leadership development could be
nursing home staff. Third, the use of a convenience sam- an important first step.
ple may also limit generalizability. Fourth, the small
sample size does not allow comparisons of leadership
Conclusions
styles between nursing homes, hindering further sub-
Our study describes that passive-avoidant leadership
group analysis. Fifth, in this descriptive study partici-
styles are excessively present in contrast to transform-
pants rated leadership styles of their direct leader using
ational leadership styles in nursing homes. Given the im-
the well-established MLQ-5X questionnaire [21]. More
portance of leadership to face current and future
nursing home outcome data would need to be evaluated
challenges, these findings indicate an urgent need to in-
to make more declarative statements of the value of dif-
vest in leadership development in nursing homes. To
ferent leadership styles and outcomes. Furthermore, add-
promote transformational leadership, future research
itional qualitative data could have provided a deeper
should focus on interventions for leadership develop-
understanding of the results.
ment. Prior to this, an instrument to measure leadership
in the specific context of nursing homes should be de-
Implications for research
veloped. This instrument could in turn support the de-
First, although the MLQ-5X visualizes a broad range of
velopment of transformational leadership in nursing
leadership styles, reliability analysis reveal poor Cron-
homes.
bach’s alpha values for some subscales. This possibly in-
dicates unsuitability of conceptualizations for the Abbreviations
relevant items. Therefore, future research should focus DoN: Director of Nursing; ERS: European Reference Scores; FRLM: Full Range
on the development of an instrument specifically de- of Leadership Model; MLQ-5X: Multifactor Leadership Questionnaire 5X;
NH: Nursing home
signed to measure leadership in the context of nursing
homes. Second, given our results, future research should
Acknowledgements
focus on developing interventions to convert passive- The authors would like to thank Mind Garden Inc. for giving permission to
avoidant leadership styles to transformational styles on use the Multifactor Leadership Questionnaire form 5X, developed by Bruce
different levels within nursing homes. Avolio and Bernard Bass.

Implications for practice Authors’ contributions

Design of the study: JP, MV, KM and EV. Data collection and analysis: JP and
The presence of passive-avoidant leadership styles in EV. Interpretation: JP, MV, KM and EV. Drafting the manuscript: JP. Critical
nursing homes may negatively influence their resilience revisions, revisions and approval of final manuscript: JP, MV, KM and EV.
to face the predicted daunting challenges. On the one Supervision: EV. The author(s) read and approved the final manuscript.
hand, the constraints present in nursing homes may hin-
der the development of well-established transformational Funding
This study was supported by the Flemish Ministry of Welfare, Public Health
leadership in head nurses and DoN. On the other hand, and Family. The Flemish Ministry of Welfare, Public Health and Family did
passive-avoidant and transactional leadership styles are not play a role in the elaboration of this study.
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