An integrative review of nursing leadership in Saudi Arabia.

AIMS: The aims of this integrative review were to describe leadership styles from the nursing literature in Saudi Arabia and to identify the current state of evidence about relationships between leadership styles and nurse, patient and organization outcomes in Saudi Arabia.
DESIGN: Integrative review was used as a design for this study.
METHODS: The following search terms were used with databases: 'Saudi Arabia', 'leadership theory*', 'leadership style*', 'leadership model*', 'management style' and 'nurse*'. Methodological quality was assessed using two different quality rating tools for quantitative and qualitative studies. Databases used for this review included Nursing & Allied Health Database, Cochrane Database of Systematic Reviews, PubMed, CINAHL, Embase, PsycINFO, Scopus, Web of Science and ProQuest Dissertations & Theses.
RESULTS: Nine manuscripts representing eight studies were included in this review. The papers reviewed included quantitative (n = 6), qualitative (n = 2) and mixed methods studies (n = 1). Results were grouped into different themes, identified as nursing leadership styles in Saudi Arabia, leadership styles and nurses' outcomes, and demographics and leadership styles.

INTRODUCTION

Research examining leadership in nursing has increased over the past decade, with more emphasis on the role of nurse managers/leaders in healthcare organizations (Azaare & Gross, 2011; Barr & Dowding, 2019). Leadership focuses on how leaders can influence change and encourage their followers to generate change (Barr & Dowding, 2019). Leadership includes the ability to influence followers through guiding, motivating and directing in order to achieve effective organizational outcomes (Cai et al., 2019; Ellis & Hartley, 2009). As leaders, nurse managers are responsible for creating hospital environments where nurses feel supported and motivated (Abualrub & Alghamdi, 2012). Evidence shows that the following leadership theories have been extensively investigated in a variety of professions, including nursing: transactional leadership, transformational leadership, situational leadership and authentic leadership (Schreuder et al., 2011). Also, there are many leadership styles that nurse managers and leaders use to lead staff nurses in clinical settings such as classical leadership (autocratic, democratic, laissez‐faire, bureaucratic and situational) and contemporary leadership (charismatic, transactional, transformational, connective and shared leadership; Huber, 2017; Major, 2019). Nurse managers' leadership styles in hospitals could influence nurses staff outcomes such as job satisfaction (AL‐Hussami, 2008). In addition, their leadership styles can impact positively or negatively on different aspects of healthcare systems including staff satisfaction and retention, which in turn can impact on the quality of healthcare delivered to patients (Barr & Dowding, 2019; Major, 2019).

In Saudi Arabia, there is no current evidence of advanced leadership programmes being introduced for nurse managers in nursing education and practice (Alghamdi et al., 2019). Alkahtani (2016) found that leadership style was the most important factor affecting nurses' attitudes and behaviours. Leadership style is the individual leader's approach to providing directions, implementing plans and encouraging followers (Northouse, 2015). There is evidence that nurse managers and their leadership styles can have direct and substantial effects on staff, patient and organization outcomes (Cummings et al., 2018); however, there is very little research on the leadership styles of nurse managers in Saudi Arabia (El Dahshan et al., 2017; Saleh et al., 2018).

BACKGROUND

Leadership styles can be divided into two major categories, which focus on human relationships or task completion. Relational‐focused leadership styles, which concentrate on people and relationships, include transformational leadership (Bass & Avolio, 1994), resonant leadership (Boyatzis & McKee, 2005; Goleman et al., 2002) and authentic leadership (Gardner et al., 2005; Walumbwa et al., 2008). Task‐focused leadership styles, which mainly focus on tasks and activities rather than relationships, include transactional leadership (Bass & Avolio, 1994), dissonant leadership (Goleman et al., 2002) and instrumental leadership (Avolio et al., 1999). There are a number of different leadership theories that have been used in the nursing literature including transformational leadership (Bass & Avolio, 1994), emotional intelligence/resonant leadership (Goleman, 1995), charismatic leadership (Conger & Kanungo, 1998) and leader–member exchange theory (Graen & Uhl‐Bien, 1995); all of which are considered as relationally focused leadership styles.

Effective leadership is needed to develop nurses and nurse leaders in order to support their visions and enhance nursing care delivery processes and outcomes (Laschinger et al., 2008; Smith et al., 2006; Tropello & DeFazio, 2014). Some relationally focused leadership theories, including transformational leadership and authentic leadership, suggest that leaders embodying these styles make ethical decisions, which lead to better outcomes (Banks et al., 2016; Bass et al., 2003; Goleman et al., 2002; Wong & Giallonardo, 2013). Cummings et al. (2018) conducted a systematic review of studies that examined the relationships between various styles of leadership and outcomes for the nursing workforce and their work environments. Review results suggested that relationally focused leadership styles contribute to positive outcomes compared with task‐focused leadership styles. For instance, 52 of 57 studies reviewed reported that relational leadership styles were associated with higher nurse job satisfaction; moreover, 16 of the 57 studies reported that task‐focused leadership styles were associated with lower nurse job satisfaction. However, given the current under‐resourced reality faced by many healthcare leaders, and nurse leaders specifically, they become primarily task‐focused and use task‐focused leadership theories such as transactional leadership theory to support their practice (Cummings et al., 2018).

Several issues described in the Saudi nursing literature are reported to be affected by leadership styles such as nurse staff shortages, job satisfaction and intention to leave the job (Aboshaiqah, 2016; Zaghloul et al., 2008). Retention of nurses staff was found as an essential factor for healthcare organizations in Saudi Arabia, and it was related to other factors such as job satisfaction (Abualrub & Alghamdi, 2012; Al‐Ahmadi, 2009). Zaghloul et al. (2008) illustrated that effective leadership is essential for improving work outcomes including nurses' job satisfaction and retention. According to Abualrub and Alghamdi (2012), nurse leaders have an effective role in enhancing staff satisfaction and retention, because they facilitate building healthy work environments by encouraging nurses to be involved in making decisions and promoting open communication and active involvement in unit decision‐making. Giving more research attention to the importance of nursing leadership styles and their relationships with nurse outcomes may help increase our understanding of what makes leadership more effective in the nursing profession (Eneh et al., 2012; Lavoie‐Tremblay et al., 2016). Nonetheless, little is currently known about the impact of leadership styles on nurse outcomes in Saudi Arabia (Al‐Yami et al., 2018). Therefore, there is a need to have a better understanding of the nature of nurse managers' leadership styles in Saudi Arabia.

The integrative review method allows for the inclusion of research using different methodologies such as experimental and non‐experimental research; it also plays a significant role in evidence‐based practice for nursing (Whittemore & Knafl, 2005). In this type of review, past empirical or theoretical literature is summarized in order to provide a more comprehensive understanding of a particular phenomenon or healthcare problem (Broome, 1993). Also, integrative reviews have been advocated as important to nursing science, research and practice (Estabrooks, 1998; Kirkevold, 1997). Integrative reviews can also be useful for defining concepts, reviewing theories and evidence and analyzing methodological issues of a specific topic (Broome, 1993).

THE STUDY

Aims

The purposes of this integrative review were to describe leadership styles from the nursing literature in Saudi Arabia and to identify the current state of evidence about the relationships between leadership styles and nurse, patient and organization outcomes in Saudi Arabia.

Research questions

The research questions that guided this integrative review were

What leadership styles have been examined in nursing leadership research in Saudi Arabia?

What are the relationships between nursing leadership styles and nurse, patient and organization outcomes in Saudi Arabia?

Design

Integrative review was used as a design for this study. Whittemore (2005) described five stages in order to enhance rigour in integrative reviews based on Cooper's (1998) framework as applied to the systematic review and meta‐analysis methods. Therefore, Whittemore mentioned five essential stages for integrative reviews, which are problem identification, literature search, data evaluation, data analysis and data presentation.

Method

The search strategy for this integrative review work was completed in August 2020, and the databases that were used for searching were Nursing & Allied Health Database, Cochrane Database of Systematic Reviews, PubMed, CINAHL, Embase, PsycINFO, Scopus, Web of Science and ProQuest Dissertations & Theses. These databases include health‐related research specific to healthcare disciplines including nursing. The following search terms were used with all databases: ‘Saudi Arabia’, ‘leadership theory*’, ‘leadership style*’, ‘leadership model*’, ‘management style’ and ‘nurse*’. Table 1 illustrates the search terms and databases and results of the searches that were used in the study. These search terms were selected based on a preliminary review of the literature and consultations with the university librarian and key information. EndNote was used as the reference management system for this integrative review. In addition to using electronic databases, we also conducted hand searches of reference lists of relevant articles and scanned specific journals that are related to the topic of this review, such as Journal of Nursing Management and Health Care Management Review.

TABLE 1

Search strategy and search results

Database/source	Search terms	Number of titles and abstracts
Nursing & Allied Health Database	‘Saudi Arabia’ AND ‘leadership theory*’ OR ‘leadership style*’ OR ‘leadership model*’ OR ‘management style’ AND ‘nurse*’	15
Cochrane Database of Systematic Reviews	‘Saudi Arabia’ AND ‘leadership theory*’ OR ‘leadership style*’ OR ‘leadership model*’ OR ‘management style’ AND ‘nurse*’	0
PubMed	Nursing theories	3
	Leadership
	Saudi Arabia
CINAHL	Nursing theories	37
	Leadership
	Saudi Arabia
Embase	Nursing theories	3
	Leadership
	Saudi Arabia
ProQuest Dissertations & Theses	‘Saudi Arabia’ AND ‘leadership theory*’ OR ‘leadership style*’ OR ‘leadership model*’ OR ‘management style’ AND ‘nurse*’	122
PsycINFO	‘Saudi Arabia’ AND ‘leadership theory*’ OR ‘leadership style*’ OR ‘leadership model*’ OR ‘management style’ AND ‘nurse*’	53
Scopus	‘Saudi Arabia’ AND ‘leadership theory*’ OR ‘leadership style*’ OR ‘leadership model*’ OR ‘management style’ AND ‘nurse*’	17
Web of Science	‘Saudi Arabia’ AND ‘leadership theory*’ OR ‘leadership style*’ OR ‘leadership model*’ OR ‘management style’ AND ‘nurse*’	2011
Total		2261

The inclusion and exclusion criteria for this review were identified based on the research questions. Titles and abstracts of each study were selected based on the following inclusion criteria: peer‐reviewed research; English language full‐text publication available; full‐text published between January 2000 and August 2020; involve nurse leaders or managers in a variety of healthcare settings; measure nursing leadership theories; conducted in Saudi Arabia; and measure relationships between nursing leadership theories and other variables. All types of studies were included, which are quantitative, qualitative and mixed method studies as well as theses and dissertations.

Two screening stages were used for selecting articles for the review. The first screening stage included the review of all titles and abstracts by using the above inclusion and exclusion criteria. The first and second authors screened all titles and abstracts to ensure validity of the screening process. All articles that passed the first stage proceeded to full‐text screening. All full‐text manuscripts were screened by the primary researcher and the second author.

Search outcome

The electronic database search yielded 2261 titles and abstracts (see Table 1). After removal of duplicates, a total of 2127 titles and abstracts were screened by using inclusion and exclusion criteria in order to select the eligible articles for inclusion. The title and abstract review of the database search results yielded 50 potentially relevant manuscripts to be retrieved for full‐text review in addition to two articles that were found by manual searching in reference lists of relevant articles, for a total of 52 candidate articles.

Quality appraisal

The primary researcher assessed each included study for methodological quality using two different quality rating tools for quantitative and qualitative studies. For the mixed methods study, a quantitative tool was used to evaluate the quantitative part and the qualitative tool to assess the qualitative part. For quantitative studies, the quality appraisal tool used in this review was adapted from other published reviews (Cowden et al., 2011; Cummings & Estabrooks, 2003; Cummings et al., 2008, 2010; Germain & Cummings, 2010; Wong & Cummings, 2007). This tool assesses four major criteria, which are research design, sample, measurement/instrument and statistical analysis. Thirteen criteria were assessed, and the total maximum score is 14. Thus, studies can be categorized as low (0–4), moderate (5–9) or high (10–14). For qualitative studies, the Critical Appraisal Skills Programme tool was used, which consists of 10 questions related to rigour, credibility and relevance (CASP, 2010). The highest score is 9 in this tool.

All studies were rated as high quality, so none of them were excluded. The results for the design section included all five quantitative studies, and the quantitative part of the mixed methods study was prospective; three quantitative studies used probability sampling, whereas two quantitative studies and the quantitative part of mixed methods did not. For the sample section, only two quantitative studies justified the sample size; all five quantitative studies and the quantitative part of mixed methods were drawn from more than one site; anonymity was protected in all studies; two quantitative studies and the quantitative part of the mixed methods study had response rates of more than 60%. For the measurement evaluation, all five quantitative studies and the quantitative part of the mixed methods study reported reliability and validity of instruments and had an internal consistency ≥0.70; only one quantitative study and the quantitative part of the mixed methods study used a theoretical model/framework to guide their studies. The last criteria was for statistical analysis; all five quantitative studies and the quantitative part of the mixed methods study used correlation and multiple regression to analyze the data. Table 2 presents a summary of the quality assessment for five quantitative studies and the quantitative part of the mixed methods study.

TABLE 2

Summary of quality assessment for the six quantitative studies—(includes five quantitative only studies, one quantitative part of mixed method study)

Criteria	Number of studies
Scores	Yes (= 1)	No (= 0)
Design
Prospective studies	6	0
Used probability sampling	3	3
Sample
Appropriate/justified sample size	2	4
Sample drawn from more than one site	6	0
Anonymity protected	6	0
Response rate >60%	3	3
Measurement
Reliable measure of leadership	6	0
Valid measure of leadership	6	0
Leadership style was observed rather than self‐reported a	6	0
Internal consistency ≥0.70 when scale was used	6	0
Theoretical model/framework used	2	4
Statistical analyses
Correlations analyzed when multiple effects studied	6	0
Management of outliers addressed	6	0

Low (0–4); medium (5–9); High (10–14). High (n = 6).

This item scored 2 points. All others scored 1 point.

The results of the qualitative study appraisal showed that of the three qualitative studies reviewed, one qualitative study and the qualitative part of the mixed methods study were rated as 8 out of a maximum score of 9, whereas the other qualitative study was rated as 9. All of them had a clear statement of the aims; used appropriate study designs, methodology, recruitment strategy and data collection; considered ethical issues; had sufficient data analysis; and had a clear statement of findings. However, only one qualitative study described the relationship between the researcher and participants in terms of any involvement with the participants prior to recruitment. Table 3 illustrated the summary of quality assessment for two qualitative studies and the qualitative part of mixed method study.

TABLE 3

Summary of the quality assessment for the three qualitative studies—(includes two qualitative only studies and the qualitative part of the mixed method study)

Criteria	Number of studies
Scores	Yes (= 1)	No (= 0)
Clear statement of research aims	3	0
Appropriate methodology	3	0
Appropriate research design	3	0
Appropriate recruitment strategy	3	0
Appropriate data collection	3	0
Relationship between the researcher and participants described	1	2
Ethical issues considered	3	0
Sufficient data analysis	3	0
Clear statement of findings	3	0
Total score: 9	2 studies = 8	1 study = 9

Data abstraction

In this phase, descriptive data from each of the included articles were categorized and summarized in order to integrate their results (Whittemore, 2005). Data that were extracted from the studies included author, journal, study purpose, theoretical framework, design, sample, measurement/instruments, analysis and findings (Table 4).

TABLE 4

Characteristics of included studies

Study	Author(s)/journal	Purpose/conceptual framework	Design	Subjects/sample	Measurement/instrument	Analysis	Findings
1a	Abualrub, R. F., and Alghamdi, M. G. (2012). Journal of Nursing Management, 20(5), 668–678	To examine the impact of leadership styles of nurse managers on Saudi nurses' job satisfaction and their intent to stay at work	A descriptive correlational design	600 nurses who are (1) holding a registered nursing license and practicing as a registered nurse, (2) having at least 6 months of experience in their current job and (3) working under the direct supervision of a nurse manager in a hospital setting in the selected hospitals (6 public hospitals in the Western Region of Saudi Arabia; convenience sample)	Leadership styles: Multifactor Leadership Questionnaire (MLQ‐5X; Bass & Avolio, 1994)	Descriptive statistics	There was a significant/positive correlation between transformational leadership (TFL) style and nurses' job satisfaction (r = .45; p < .001), whereas a significant/negative relationship between transactional leadership (TAL) style and job satisfaction (r = .14; p < .01)
				Response rate = 51.3%; final n = 308	Job satisfaction: Job Satisfaction Survey (JSS; Spector, 1985)	Pearson's correlation	There was a significant weak correlation in the positive direction between nurses' job satisfaction and nurses intention to stay at work (r = .15; p <.01)
				Demographics:	Intention to stay at work: McCain's Intent to Stay Scale (McCloskey & McCain, 1987)	Hierarchical regression	The relationship between the TFL style and the level of intent to stay was statistically insignificant (r = .08; p = .14) as well as the relationship between the TAL style and the level of intent to stay (r = .01; p = .81)
				Reported: Yes			Participants perceived their managers as transformational leaders rather than transactional leaders
1b	Alghamdi, M. G., Topp, R., and AlYami, M. S. (2018). Journal of Advanced Nursing, 74(1), 119–127	To compare nurses' job satisfaction and perceptions of TFL style of their manager among four different nurse/manager gender dyads in Saudi Arabia	A descriptive analysis of one‐time survey (a secondary analysis)	600 nurses who are (1) holding a registered nursing license and practicing as a registered nurse, (2) having at least 6 months of experience in their current job and (3) working under the direct supervision of a nurse manager in a hospital setting in the selected hospitals (6 public hospitals in the Western Region of Saudi Arabia; convenience sample)	Job satisfaction: JSS (Spector, 1985)	Descriptive statistics	Job satisfaction indicated a main effect of gender of the manager (F = 51.8; p < .001) with staff nurses who worked under the leadership of male managers more satisfied than those who worked under female managers
				Response rate = 51.3%; Final n = 308			A main effect of the manager's gender on the nurse's perceptions of their manager's TFL style (F = 156.8; p > .001)
				Demographics:	TFL style: MLQ‐5X (just TFL subscales; Bass & Avolio, 1994)	ANOVA	The results indicated that nurses who worked under the leadership of a male manager perceived higher TFL style compared with the other subordinates who worked under the leadership of a female manager
				Reported: Yes
2	Alshahrani, F. M. M., and Baig, L. A. (2016). Journal of the College of Physicians and Surgeons Pakistan, 26(5), 366–370	To evaluate the effect of TFL and TAL styles of head nurses on the job satisfaction of staff nurses in critical care units (CCUs) of a tertiary care hospital	A cross‐sectional study	160 licensed nurses, working under direct supervision of a head nurse with a minimum of 6 months of experience in CCUs (Aseer Central Hospital, reporting to eight nurse leaders; convenience sample)	Leadership styles: MLQ‐5X (Bass & Avolio, 1994)	ANOVA	The majority of the head nurses demonstrated TAL style
				Response rate = 59%; final n = 89			Nurses working under leaders with a transformational style demonstrated significantly (p <.05) higher job satisfaction.
				Demographics:	Job satisfaction: JSS (Spector, 1985)	Multiple linear regression analysis	There were statistically significant differences between eight head nurses' leadership styles as well as nurses' job satisfaction
				Reported: Yes
3	Asiri, S. A., Rohrer, W. W., Al‐Surimi, K., Da'ar, O. O., and Ahmed, A. (2016). BMC Nursing, 15(1), 38	To investigate the relationships among leadership style, psychological empowerment and organizational commitment	A cross‐sectional survey	350 questionnaires were randomly distributed to full‐time registered nursing staff in the acute care units at King Abdulaziz Medical City in Riyad	Leadership styles: Multifactor Leadership Questionnaire (MLQ; Bass & Avolio, 1994)	Pearson's correlation	Nurses' commitment was significantly negatively correlated with meaning dimension of commitment (r = −.130; p = .019) and TFL (r = −.113; p = .045)
				Response rate = 95%; final n = 332	Psychological empowerment: Psychological Empowerment Scale (Spreitzer, 1995)	Stepwise regression	Nurses' commitment was significantly positively correlated with TAL (r = .124; p = .028)
				Demographics:	Organizational commitment: Three‐component model of employee commitment (Allen & Meyer, 1996)	ANOVA	Nurses' perception of leadership styles (TAL and laissez‐faire) had positive and significant effects on commitment (p = .027 and.012), respectively
				Reported: Yes			The psychological empowerment subscale, autonomy was the only statistically significant predictor of commitment
4	El Dahshan, M. E. A., Youssef, H. A., Aljouaid, M., Babkeir, R. A., and Hassan, W. B. (2017). Global Journal of Management and Business Research, 17(6), 0975–5853	To explore and describe nurse managers' leadership styles and its effect on nurses' organizational commitment at Taif governmental hospitals in Kingdom of Saudi Arabia	A cross‐sectional descriptive survey	A random sample of 570 nurses worked in King Faisal Specialized Hospital (KFSH) and King Abdulaziz Specialized Hospital (KASH) and have at least 1 year of experience and working at study settings	Leadership style: Leadership Style Questionnaire (Vera & Crossan, 2004)	Descriptive statistics	Most of participant nurses (74.4%) perceived their leaders as transformational leaders, whereas 65.6% of them perceived their leaders as transactional leaders in both hospitals
				Response rate = N/A; final n = 570		Pearson's correlation	Majority (87.1%) of participant nurses had commitment to their organization in KFSH, and 76.8% of participant nurses had commitment to their organization in KASH
				Demographics:	Organization commitment: Organization Commitment Questionnaire (Meyer, 2004)	Chi‐square	There was statistically significant positive correlation between TFL style and organizational commitment in each hospital
				Reported: Yes			There was positive correlation between TAL style and organizational commitment in KASH but significant positive correlation in KFSH
5	Al‐Yami, M., Galdas, P., and Watson, R. (2018). Journal of Nursing Management, 26(5), 531–539	To examine how nurse managers' leadership style and nurses' organizational commitment are related in Saudi Arabia	A quantitative survey design	232 nurses randomly selected from two medical cities in Riyadh, Saudi Arabia	Leadership styles: MLQ (Bass, 1985)	t‐tests	TFL and organizational commitment were positively related represented by value commitment and commitment to stay (r = .374; p < .01 and r = .345, p < .01, respectively)
		Full range of leadership model (Bass, 1985)		Response rate = 84%; final n = 219		Pearson's correlation	TAL is more strongly related to commitment than to TFL
				Demographics:	Organizational commitment: Organizational Commitment Questionnaire (Mowday et al., 1979)	Hierarchical regression	Passive/avoidant leadership and commitment were negatively correlated (r = −.240; p < .01 and r = −.240; p < .01, respectively)
				Reported: Yes			Both management‐by‐exception passive and laissez‐faire leadership styles have negative correlations with both value commitment and commitment to stay
							No significant difference was found between marital status, level of education and leadership styles and their subscales, whereas age has significant relationships with TFL and transformational subscales
6	Aldawood, A. (2017). Doctoral dissertation, Cardiff University.	To understand the relationship between nurse leadership and cultural differences in Saudi Arabia's hospital settings	A qualitative design	Nurse directors (n = 8), head nurses (n = 23) and staff nurses (n = 15)	In‐depth interviews and focus groups	The transcribed documents	Three main themes emerged from an analysis of all the transcripts: (1) Gendered aspects of nursing in Saudi Arabia; (2) unique personal leadership qualities; and (3) What works?
		To identify the future training and development needs of nurse leaders in Saudi Arabia		30 of these participants were equally distributed among six focus groups, whereas 16 were interviewed separately at King Saud Medical City		Coding	(1) Gendered aspects of nursing in Saudi Arabia: The issue of the gender‐based segregation inherent to Saudi culture, sanctioned by society and enforced through government structures
		The cultural competence model (Papadopoulos, 2006)		Final n = 46		Thematic analysis	(2) Unique personal leadership qualities: Leadership emerged as a key skill in these data for nurses at all levels
				Demographics			(3) What works? Examine what works and also what may not when leading nursing in Saudi Arabia
				Reported: Yes
7	Saleh, U., O'Connor, T., Al‐Subhi, H., Alkattan, R., Al‐Harbi, S., and Patton, D. (2018). British Journal of Nursing, 27(4), 197–203	To explore the nature of leadership styles used by the nursing management team, as perceived by nurses working at the bedside	Qualitative methodology	Purposive, non‐probability sample of 35 nurses who are in a full‐time position with a minimum of 1‐year experience in different specialties of a medical city in Saudi Arabia	Semi‐structured interview	A phenomenological hermeneutic approach inspired by Ricoeur's philosophy, a five‐phase process (Ricoeur, 1976)	Four themes emerged: Relational, preferential, communication chain and ineffectual leadership styles
				Demographics:			(1) Relational leadership style: The relationship was viewed as a cooperation between ward nurses and the nursing leadership team to produce the best possible patient outcomes
				Reported: Yes			(2) Preferential leadership style: Participants were dissatisfied because of the preferential style employed by head nurses and/or charge nurses
							(3) Communication chain leadership style: Participants were able to identify the chain of communication at the institution, which was composed of the charge nurse/head nurse, the nursing director and the chief nursing officer
							(4) Ineffectual leadership style: Nurses would like to see improvement in their managers' leadership styles
8	Omer, T. Y. (2005). Doctoral dissertation, George Mason University	To assess the leadership style of nurse managers working at National Guard Hospitals in Saudi Arabia	Mixed methods	146 nurses who work in National Guard Hospital in Jeddah and 269 from National Guard Hospital in Riyadh; 23 nurse managers	For quantitative part: Leadership style: MLQ‐5X (Bass, 1985)	For quantitative part:	The quantitative results of this study indicated that the nurse managers as well as the staff nurses working with them perceived that the leadership style of the nurse managers at the Saudi National Guard was a mix of both transformational and transactional styles
		To explore the correlation of their perceived leadership style to certain organizational outcomes, including leader effectiveness, staff job satisfaction and staff willingness to exert extra effort		Response rate = 65.3%; Final n = 271		Confirmatory Factor Analysis ( CFA)	Both nurse managers and staff nurses gave a higher rating to transformational factors than transactional factors
		TFL model (Bass, 1985)		Demographics:	For qualitative part: Narrative interview (Heideggerian Phenomenological‐Hermeneutic Approach, 1962)	ANOVA	Nurses rated the nurse managers significantly lower in all nine leadership factors
				Reported: Yes		Multiple linear regression	There was no significant difference between the demographic characteristics in regard to the perceived leadership style of the nurse managers
						For qualitative part: A phenomenological‐hermeneutic approach	The main themes that emerged from qualitative part are as follows: leadership process, work environment and work relationship

Abbreviations: ANOVA, analysis of variance; N/A, not applicable.

Descriptive characteristics of each study are explained in Table 4. All studies were published between 2005 and 2018, and each study was published in a different journal or university. Participants in all eight studies were registered nurses working in the healthcare settings associated with each study. Two unpublished studies (doctoral dissertations) included nurse managers and head nurses in their sample (Aldawood, 2017; Omer, 2005).

All quantitative, qualitative and mixed methods studies aimed to examine the leadership styles of nurse managers that were measured based on different theories and their relationships with various outcomes. Only one quantitative study and one mixed methods study used a theoretical framework as guidance for the study (Al‐Yami et al., 2018; Omer, 2005). Two main leadership instruments were used in the five quantitative studies and one mixed methods study: the Multifactor Leadership Questionnaire to measure transactional, transformational and laissez‐faire leadership styles (Abualrub & Alghamdi, 2012; Alshahrani & Baig, 2016; Al‐Yami et al., 2018; Asiri et al., 2016; Bass, 1985; Omer, 2005) and the Leadership Style Questionnaire to measure transactional and transformational leadership styles (El Dahshan et al., 2017; Vera & Crossan, 2004).

Synthesis

Data extracted from the reviewed studies were grouped into different themes based on the similarities in meaning that address the purpose of this integrative review and research questions. These themes are nursing leadership theories in Saudi Arabia, leadership styles and nurses' outcomes, and demographics and leadership styles.

RESULTS

Nine manuscripts representing eight studies were included in this review. Two papers counted as one study because there was a second paper (a secondary analysis) from one of the studies (Abualrub & Alghamdi, 2012; Alghamdi et al., 2018); therefore, these two articles were counted as one study in the analyses and results. A summary of the search strategy and screening process results is explained in Figure 1.

FIGURE 1

Selection of articles for review

There were six manuscripts representing five original quantitative studies, as well as two qualitative studies, and one mixed methods study. Two manuscripts were unpublished doctoral dissertations: one was a qualitative study and the other a mixed method study. Quantitative studies were all non‐experimental, correlational studies (n = 6). Both qualitative studies used a qualitative descriptive design. For the mixed methods study, the author used a non‐experimental, correlational design for the quantitative part and a phenomenological approach for the qualitative part.

The following themes are the results of narrative analysis.

Nursing leadership styles in Saudi Arabia

The main goal of all but one of the included studies was to assess the types of leadership styles of nurse managers in Saudi Arabia. One study focused only on assessing transformational leadership styles (Alghamdi et al., 2018). It was found that transformational, transactional, laissez‐faire, passive/avoidant and management‐by‐exception passive leadership styles were the most leadership styles that have been examined in nursing studies in Saudi Arabia. Four studies showed that transformational leadership and transactional leadership styles were the most common nursing leadership styles reported based on how the study nurses perceived their leaders as (Abualrub & Alghamdi, 2012; Alshahrani & Baig, 2016; El Dahshan et al., 2017; Omer, 2005). Nonetheless, laissez‐faire leadership style was also found as a preference for some nurse managers in Saudi Arabia (Abualrub & Alghamdi, 2012; Al‐Yami et al., 2018; Asiri et al., 2016; El Dahshan et al., 2017).

Abualrub and Alghamdi (2012) found that participants perceived their managers as transformational leaders or transactional leaders, but the mean transformational leadership score was higher (M = 3.43; SD = 0.82) than for transactional leadership (M = 2.98; SD = 0.57) as it was rated by nurses (Abualrub & Alghamdi, 2012). In another study, the authors explored the nurse managers' leadership styles and its effect on nurses' organizational commitment at two governmental hospitals in Saudi Arabia: King Faisal Specialized Hospital (KFSH) and King Abdulaziz Specialized Hospital (KASH; El Dahshan et al., 2017). The results of this study indicated that 74.4% of participant nurses perceived their leaders as transformational leaders, whereas 25.6% of them were seen as non‐transformational leadership style in both hospitals. On the other hand, 65.6% of the participants perceived their leaders as transactional leaders, whereas 34.4% of them non‐transactional leadership style in both hospitals (El Dahshan et al., 2017).

The quantitative results of the mixed methods study indicated that staff nurses perceived that their nurse managers at the Saudi National Guard Hospital used a combination of both transformational and transactional leadership styles (Omer, 2005). Omer (2005) also found that there is a difference in mean scores between nurse managers' self‐ratings and staff nurse ratings. Therefore, the mean score of transformational leadership styles by nurse managers was M = 3.13 and SD = 0.47, whereas the score when nurses rated their managers was lower (M = 2.22; SD = 0.96). Similar results applied to transactional leadership. Nurse managers who rated themselves as high on transactional leadership (M = 3.18; SD = 0.48) were rated lower on that dimension by their staff nurses (M = 2.21; SD = 0.95). However, nurse managers who rated themselves as low on laissez‐faire leaders (M = 0.42; SD = 0.50) were rated higher on that dimension by their staff nurses (M = 1.27; SD = 0.50). In a more recent study, Alshahrani and Baig (2016) found that the majority of nurses rated their head nurses as using a transactional leadership style compared with a transformational leadership style; thus, the mean score of transactional leadership style (M = 3.58; SD = 0.68) was higher than the mean score of transformational leadership style (M = 3.32; SD = 0.72).

The results of the qualitative studies also focused on the nature of leadership styles used by nurse managers in Saudi Arabia and its impacts on nurses' outcomes. Qualitative studies illustrated the essential role of nurse leaders and their behaviours on increasing healthy work environments in general. Saleh et al. (2018) found that nurses reported that there is a need for their nurse managers to enhance their leadership skills by receiving training leadership competencies such as effective communication, conflict resolution and building a good relationship with nurses. In addition, their study results showed that the nature of leadership styles of nurse leaders may have a major impact on nurses' satisfaction, which in turn affects their engagement levels and turnover intentions, and ultimately, the quality of care that they provide to their patients may be affected (Saleh et al., 2018). Behaviour of leaders and their leadership styles were found as essential components to being effective leaders (Aldawood, 2017).

Leadership styles and nurse outcomes

All included studies in this review examined the relationships between leadership styles of nurse managers and different outcomes that are related to staff nurses. There were five nurse outcomes that were examined in relation to manager leadership styles: organizational commitment (Al‐Yami et al., 2018; Asiri et al., 2016; El Dahshan et al., 2017), nurses' job satisfaction (Abualrub & Alghamdi, 2012; Alshahrani & Baig, 2016; Omer, 2005), intent to stay (Abualrub & Alghamdi, 2012), willingness to exert extra effort (Omer, 2005) and leaders' effectiveness (Omer, 2005). Table 5 illustrates the relationship between leadership styles and nurse outcomes in more details.

TABLE 5

Summary of the relationships between leadership styles and nurse outcomes

Nurse outcomes	Leadership styles
	Transformational leadership	Transactional leadership	Laissez‐faire leadership	Passive/avoidant leadership	Management‐by‐exception passive leadership
Organizational commitment	Positive and significant (Al‐Yami et al., 2018; El Dahshan et al., 2017)	Positive and significant (Al‐Yami et al., 2018; Asiri et al., 2016; El Dahshan et al., 2017)	Positive and significant (Asiri et al., 2016)	Negative and significant (Al‐Yami et al., 2018)	Negative and significant (Al‐Yami et al., 2018)
	Negative and significant (Asiri et al., 2016)	Positive but not significant (El Dahshan et al., 2017)	Negative and significant (Al‐Yami et al., 2018)
Nurses' job satisfaction	Positive and significant (Abualrub & Alghamdi, 2012; Alshahrani & Baig, 2016; Omer, 2005)	Negative and significant (Abualrub & Alghamdi, 2012)	Negative and significant (Omer, 2005)		Negative and significant (Omer, 2005)
		Positive and significant (Omer, 2005)
Intent to stay	Positive but not significant (Abualrub & Alghamdi, 2012)	Positive but not significant (Abualrub & Alghamdi, 2012)
Willingness to exert extra effort	Positive and significant (Omer, 2005)	Positive and significant (Omer, 2005)	Negative and significant (Omer, 2005)		Negative and significant (Omer, 2005)
Leaders' effectiveness	Positive and significant (Omer, 2005)	Positive and significant (Omer, 2005)	Negative and significant (Omer, 2005)		Negative and significant (Omer, 2005)

Transformational leadership has been examined in the included studies with various outcomes. It found that there was a positive and significant relationship between transformational leadership and organizational commitment (Al‐Yami et al., 2018; El Dahshan et al., 2017). However, Asiri et al. (2016) found that organizational commitment was significantly negatively correlated to transformational leadership. There was a significant and positive relationship between transformational leadership style and nurses' job satisfaction (Abualrub & Alghamdi, 2012; Alshahrani & Baig, 2016; Omer, 2005). Abualrub and Alghamdi (2012) found that that there was a positive but not significant relationship between transformational leadership style and the level of intent to stay (r = .08; p = .14). The relationship between willingness to exert extra effort and transformational leadership was positive and significant (Omer, 2005).

Transactional leadership style was also examined with the same nurse outcomes in the included studies. Transactional leadership had a significant and positive relationship with organizational commitment (Al‐Yami et al., 2018; Asiri et al., 2016). El Dahshan et al. (2017) also found that there was a positive but not significant relationship between transactional leadership style and organizational commitment in KASH, whereas there was a statistically significant positive correlation in KFSH. Transactional leadership was examined with nurses' job satisfaction, and there was a significant and negative relationship between transactional leadership style and job satisfaction (r = −.14; p < .01; Abualrub & Alghamdi, 2012), whereas Omer (2005) found the relations between nurses' job satisfaction and transactional leadership style to be positive and significant. The relationship between willingness to exert extra effort and transactional leadership style was positive and significant (Omer, 2005). Lastly, Abualrub and Alghamdi (2012) found no relationship between the transactional leadership style and the level of intent to stay (r = .01; p = .81).

Finally, laissez‐faire, passive/avoidant and management‐by‐exception passive leadership styles were examined with organizational commitment in two studies (Al‐Yami et al., 2018; Asiri et al., 2016). The relationship between laissez‐faire leadership and organizational commitment was positive and significant (Asiri et al., 2016), whereas Al‐Yami et al. (2018) found that there was a negative and significant relationship between laissez‐faire leadership and organizational commitment. The relationships between both passive/avoidant and management‐by‐exception passive leadership and organizational commitment were negative and significant (Al‐Yami et al., 2018). Also, laissez‐faire and management‐by‐exception passive leadership styles were examined with nurses' job satisfaction, willingness to exert extra effort and leaders' effectiveness and found to have negative relationships.

Demographics and leadership styles

Because there are possible relationships between demographic factors and nurse managers' leadership styles in Saudi Arabia, demographics were examined in most of the included studies (Aldawood, 2017; Alghamdi et al., 2018; Al‐Yami et al., 2018; Omer, 2005). Alghamdi et al. (2018) found that gender was a factor influencing nurse's perceptions of manager's leadership style (F = 156.8; p < .001). They concluded that nurses who worked under a male manager perceived higher transformational leadership style compared with a female manager (Alghamdi et al., 2018). Aldawood (2017) also found that in his qualitative study, gendered aspects of nursing in Saudi Arabia were considered to be the main issue because of gender‐based segregation in the healthcare system. The results of his study showed that gender issues were considered as one of the significant obstacles for female nurse leaders in Saudi Arabia.

Age also has a significant positive relationship with transformational leadership style of nurse managers (Al‐Yami et al., 2018). However, two studies found that there were no significant differences between marital status and level of education and leadership style of the nurse managers (Al‐Yami et al., 2018). Omer (2005) found that there were no significant relationships between age, gender, marital status, level of education and transformational, transactional and laissez‐faire leadership styles. Nonetheless, there were significant relationships between ward, type of care unit and position and transformational, transactional and laissez‐faire leadership styles (Omer, 2005).

DISCUSSION

The findings of this review indicate that transformational, transactional, laissez‐faire, passive/avoidant and management‐by‐exception passive leadership styles were the only leadership styles that have been examined in nursing studies in Saudi Arabia. However, the two leadership styles found to be the most often used by nurse managers were transformational leadership and transactional leadership styles. These results support a previous review that found that relationally focused leadership styles were commonly used by nurse managers in other countries (Cummings et al., 2018). Cummings et al.'s review (2018) also found that other different styles were used by nurse managers, including socio‐emotional, consideration, authentic, inspirational, charismatic and resonant styles. However, these styles were not examined in the nursing leadership literature in Saudi Arabia.

The results of this review support a relationship between leadership styles of nurse managers and different staff nurse outcomes. Five nurse outcomes that were found in the reviewed studies and had relationships with leadership styles included organizational commitment, nurses' job satisfaction, intent to stay, willingness to exert extra effort and leaders' effectiveness. The findings of this review support positive and significant relationships between transformational leadership and organizational commitment and nurses' job satisfaction. The review findings also suggest that there are positive and significant relationships between transactional leadership and organizational commitment and nurses' job satisfaction. However, there was also a negative and significant relationship between transactional leadership style and job satisfaction (Abualrub & Alghamdi, 2012). This negative result concurs with a previous review by Cummings et al. (2018) who reported that task‐focused leadership styles were less likely to enhance positive outcomes or to reduce negative outcomes. The results of this review support what was found in a previous study related to the negative associations between passive leadership styles and outcomes (Derue et al., 2011). The review illustrates that passive/avoidant leadership and management‐by‐exception passive leadership styles have negative relationships with organizational commitment, nurses' job satisfaction, willingness to exert extra effort and leaders' effectiveness.

This review's findings provide support for the relationships between nursing leadership styles, including transformational, transactional, laissez‐faire, passive/avoidant and management‐by‐exception passive leadership styles, and nurse outcomes such as organizational commitment, nurses' job satisfaction, intent to stay, willingness to exert extra effort and leaders' effectiveness. It is essential to differentiate between the various leadership styles, especially the two most common types: relationally focused and task‐focused leadership styles. The findings of this review illustrate that there is a significant gap in the nursing leadership literature in Saudi Arabia. Also, there is a gap in the nursing literature in Saudi Arabia regarding the effect of leadership styles on patient outcomes, so future researchers should pay attention to these significant gaps.

Limitations

The review was limited to identifying leadership theories that have been examined in nursing literature in Saudi Arabia; thus, the generalizability of the findings may be limited to the Saudi context. The small number of studies in the nursing literature in Saudi Arabia regarding leadership styles is another limitation that could affect the findings related to outcomes. All included studies were conducted in public hospitals in Saudi Arabia, which limited the findings to only public healthcare services, so the findings are not applicable to private healthcare sectors in Saudi Arabia. In addition, all quantitative studies used basic statistical methods to analyze the data where in the future, advanced statistical tests could be applied such as structural equation modeling. Finally, publication bias is a limitation of this review because grey literature and Arabic language studies were excluded.

CONCLUSION

The findings of this integrative review provide evidence related to nursing leadership styles including relational leadership and task‐focused leadership styles and their links to nursing outcomes. A type of relational leadership theory, transformational leadership more specifically, was found to be the only theory that has been tested in relation to nurses and their work outcomes in Saudi Arabia. Knowledge generated from this review supports the significant role that nurse managers play in nurses' job satisfaction and their intent to stay with their current organization. The results summarize the need for future studies in Saudi Arabia regarding the essential role of nurse managers and their leadership styles in enhancing the work environments and creating positive outcomes for nurses, patients and healthcare organizations. By integrating knowledge from previous studies, this review helps future researchers to focus on the gaps that need to be explored. The results suggest that nurse managers should apply the best leadership styles in their practices in order to achieve the best outcomes for both staff and patients. The crucial effect of leadership styles of nurse managers might not be directly seen on patients, but it could affect patients through the outcomes for nurses. For example, if nurses are satisfied in their work, they could provide better care to meet their patient needs. Additionally, it could affect their decision to stay or leave their current job and thus indirectly influence the quality of care through staff turnover (Cummings et al., 2018). The results of this review encourage Saudi researchers to do more studies that examine relationships between leadership styles and nurse, patient and organization outcomes. For example, although a previous review examined the impact of authentic leadership on different outcomes, none of the included studies were conducted in Saudi Arabia (Alilyyani et al., 2018). Also, only five outcomes were examined in the current review, hence the need for more studies that examine different outcomes related to health and well‐being of nurses, including the psychological states of nurses, performance of nurses and the quality of their work environment factors.

CONFLICT OF INTEREST

There is no conflict of interest.

AUTHOR CONTRIBUTIONS

All authors contributed to the conception of the study. BA and MK reviewed the included studies and screened them. CW and DW reviewed the result section to make sure about the consistency with the tables. All authors contributed to the interpretation of the results and approved the final version of the study.

ETHICAL APPROVAL

Ethical approval was not required.