A caring leadership model in nursing: A grounded theory approach.

AIM: This study aimed to develop a theoretical model of caring leadership in nursing.
BACKGROUND: Nurse leader's role plays an integral part in complex health care institutions. As a common feature of leaders, leaders' caring leadership can positively influence the stakeholders in health care institutions. Still, little is known about caring leadership in nursing, especially in the Chinese cultural background.
METHODS: Grounded theory was used to develop the theoretical model of caring leadership. Both semi-structured interviews and open-ended questionnaire surveys were used to collect data for constructing the theory model. Ten nurse leaders and 11 nurse staff were recruited for an interview, and 168 nurse leaders and 286 nurses were recruited for an open-ended questionnaire survey.
RESULTS: A theoretical model of caring leadership was developed using five core attributions: benevolent to others, appreciate the uniqueness, facilitate self-actualization, maintain mutual benefit and motivate with charisma. Caring leadership in nurse leaders works through the caring and leading process, resulting in nurses' well-being, patients' healing and organisational excellence.
CONCLUSION: A caring leadership model was developed through grounded theory, revealing Chinese nurses' perspectives on caring leadership in Chinese cultural background. According to the model, the concept of caring leadership has been further explained, and it makes contributions to the measurement and leaders' practice in health care institutions. IMPLICATIONS FOR NURSING MANAGEMENT: This caring leadership model developed in our study provides a new perspective and understanding of caring and leadership for nurse leaders. Nurse leaders need to strengthen their responsibilities and personal qualities while caring for nurse staff to improve leadership efficacy based on the theoretical model. And caring leadership can help nurse leaders to balance the interests of stakeholders, leading to positive consequences for nurse staff, patients and health care organisations.

BACKGROUND

Management in the health care system is becoming much more complicated as the health care system develops and transforms. It is constantly confronted with challenges such as limited budgets, nurse shortages and increasing patient care needs. Nurse leaders play crucial roles in balancing the health care system, nurse staff and the patient, sustaining high reliability in patient care service and leading the organisation into excellence (Arakelian et al., 2019; Bondas, 2003; Cummings et al., 2021). Developing nurse leaders has been regarded as an essential strategy to transform health care because effective leaders can instill nurse self‐efficacy and their practice behaviours (Cummings et al., 2021).

While some popular leadership types, such as transformational leadership (Fischer, 2016), ethical leadership (Barkhordari‐Sharifabad et al., 2018) and authentic leadership (Alilyyani et al., 2018), are currently being studied by nursing researchers. However, some researchers point out that nursing leadership is a human‐to‐human interaction rooted in complex micro and macro systems based on disciplinary and clinical practice characteristics, which should be valued and developed to advance nursing theory and practice (Leclerc et al., 2021; Watson et al., 2018).

Caring is regarded as the essence and core of nursing, and it is rooted in fundamental issues of human life and existence (Bergbom et al., 2021; Nasman, 2020). In clinical practice, caring is also required to alleviate patient suffering, promote healing and care for patients suffering from abortion and mental illness (Nasman, 2020). Bondas (2003) argued that without a caring perspective in patient care, the patient's suffering would not be alleviated, and the patient would be denied assistance. Furthermore, in recent years, caring has been emphasized in leadership and education (Gabriel, 2014; Li et al., 2020). Caring is also a common feature of many followers' praises for their leader. A caring leader has romantic characteristics such as compassion, kindness, trust and supportive behaviours towards followers (Abreu Pederzini, 2019; Williams et al., 2011). Leaders' caring creates an affection bonding that encourages the leader and follower to grow by forming interpersonal connections based on mutual respect and love. Caring takes place in two ways during this process: leaders ‘leaping in’ to assume responsibility for a current situation (Tomkins & Simpson, 2015). The second one is leaders ‘leaping ahead’ to show the possibility of the future (Tomkins & Simpson, 2015). In previous studies, the description of caring leaders and leaders' caring present the human‐centred altruistic values and behaviours to their followers, which helps to ensure their well‐being and flourish.

In China, leaders' caring is always mentioned by researchers when discussing leadership in an organisation. Traditional Chinese culture is centred on Confucianism, including benevolence, righteousness, propriety, wisdom and trustworthiness, embodying moral principles, values and behaviours of individuals within the Chinese cultural context (Chen et al., 2011, 2017; Zhang et al., 2012). With the deep‐rooted Confucius values, hierarchy, relationalism and morality were emphasized among leaders and followers. Hierarchy refers to leaders' authority and responsibility; relationalism refers to close interpersonal relationships; morality indicates leaders' characters and ethical behaviours. In China, leaders' caring embodies a close relationship among leaders and followers, which is essential in making effective leadership by helping to form an emotional bonding and a reciprocal relationship to enhance the role behaviours (Chen et al., 2017; Zhang et al., 2012). Hence, the individuals with the higher position are expected to close relationships with their followers and show kindness. Specifically, excellent leaders need to demonstrate an individualized and holistic concern for the well‐being of individuals and their families, indicating caring for the followers.

Caring has become a more prominent topic in organisational life in recent years. And leaders' caring has been linked to organisational commitment, anxiety reduction at work, increased workplace self‐esteem and, more tentatively, organisational performance and productivity (Kostich et al., 2020; Olender, 2017; Tomkins & Simpson, 2015). Furthermore, previous empirical studies have revealed that nursing leaders' caring behaviour positively influences staff nurses and patients (Kostich, 2020; Salinas et al., 2020), indicating the importance of caring leadership in clinical practice.

Caring leadership comes naturally from characteristics, evidenced by a supportive leader–follower relationship, which is critical to achieving the Institute of Healthcare's vision of nurses as full partners with other health care professionals (Peng et al., 2015). Eriksson's Caritative theory illustrated caring through relationships that involve love, mercy and compassion; the motive of caring is to alleviate suffering and protect well‐being (Bergbom et al., 2021). In Eriksson's theory, caring is a natural process deeply connected with human suffering and helps to understand the essence of caring. Based on Eriksson's Caritative theory, Bondas (2003) described caring leadership in health care institutions as related to motivation, human love and mercy, which consists of encompassing nurse management and patient caring, emphasizing guidance, direction, respect, and human love and compassion for employees, as well as a ministration of patients. The aim of Bondas's caring leadership focuses on patient service, contributing to creating a caring environment in health care settings. Watson's caring theory also offers a philosophical viewpoint on caring leadership. As the basis of this theory, the transpersonal caring relationship in Watson's theory conveys a concern for human life and embodies the 10 Caritatas Process, which addresses the essence of caring (Watson, 2008). Moreover, the core concepts in the 10 Caritatas Process like loving‐kindness, inspiring, trusting, nurturing, forgiving, deepening, balancing, co‐creating, ministering and opening provide principles for the leading process. Based on Watson's theory, Williams et al. (2011) developed a caring leadership model by incorporating the 10 Caritas Process and Kouzes and Posner's leadership theory, demonstrating supportive leader–follower relationships using core concepts. Their research looked into the core elements of caring leadership in health care settings, highlighting the value and significance of caring leadership in nursing care.

Both Eriksson and Watson's theories provided perspectives to understand leader's caring in health care settings; the related caring leadership model also provides frameworks for leading practice. However, these studies on caring leadership are primarily based on the critical thinking of the theory, lacking leader–follower perspectives, and were not tested with empirical studies. Furthermore, the caring theory and caring leadership model are derived from western cultural backgrounds, following the views and contributions of Chinese in a multicultural context. Thus, with a deep understanding of related theories, this study proposes to use a grounded theory method to develop a theoretical model of caring leadership with a Chinese cultural background, thereby contributing to the development and measurement of caring leadership and its application in health care practice.

METHOD

Grounded theory methodology

Corbin and Strauss's (1990) grounded theory, which is based on a pragmatic philosophical perspective, offers a methodology for researchers to better understand and explain leadership. Based on the participants' beliefs and experiences, this study employs grounded theory to determine the connotation and denotation of caring leadership in nursing. Meanwhile, the interaction process and potential consequences of caring leadership will be discussed and interpreted.

Data collection and sampling

Semi‐structured interview

From 3 November to 28 December 2020, nurse leaders and staff at a teaching hospital in Wuhan, China, were recruited using purposive and theoretical sampling. The following criteria were used to select nurse leaders: (1) at least 3 years of nursing management experience; (2) an intermediate title or higher; and (3) involvement in front‐line nursing management. Nurse leaders who had not been involved in front‐line nursing management for at least 6 months were excluded. The following were the inclusion criteria for nurse staff: (1) engaged in front‐line nursing service and (2) worked in the department for at least 2 years. The following are the exclusion criteria for nurse staff: (1) rotating nurses or training nurses and (2) not working in the clinical department for more than 6 months. According to the interviewee's preference, a semi‐structured interview was applied to collect data through face‐to‐face, telephone and online video interviews. The interview was held in a relaxed and comfortable setting, such as the interviewees' office.

In‐depth interviews were conducted with participants, who were asked the following questions: (1) What behaviours of a leader make you think she/he is a caring leader? (2) What characteristics or traits do you think a caring leader should have? (3) What kind of influence can a caring leader have? (4) How can caring leader improve their leadership effectiveness? (5) Is there anything else you had like to say? The interviews lasted 40–70 min and were filled with open‐ended questions; the interview outline was not strictly followed to obtain more information.

The interviewer was a male registered nurse and was a PhD candidate during this study. Before this study, he received systematic training in qualitative research, and he had rich experiences of conducting interviews, such as focus group interviews with nursing students.

The data were collected anonymously to protect interviewees' privacy. Each interviewee was assigned a unique number, such as L01 or N01 (L for nurse leaders; N for nurse staff). The first author transcribed the audio recordings within 24 h after the interview for further analysis.

Open‐ended questionnaire survey

An open‐ended questionnaire survey was conducted as an additional data source to provide an in‐depth understanding of a caring leader, providing mutual confirmation and ensuring the reliability and credibility of this study. The questionnaire included an introduction of this study with a brief description of caring leadership, a self‐designed demographic information questionnaire and two open‐ended questions, as follows: (1) What characteristics of a nurse leader do you believe would lead you to believe she is a caring leader? (2) What qualities do you believe a caring leader should possess? In the introduction, caring leadership described those nurse leaders concerned about the employee's well‐being and flourishing and demonstrating caring to the employees. Respondents were asked to provide at least three different descriptions for each question.

The participants were recruited through purposeful and convenient sampling in six teaching hospitals in Xiangyang and Wuhan, China. The participants, including nurse leaders and nurse staff, were able to complete it via an online platform named Wenjuanxing (https://www.wjx.cn/). The online survey link was sent to every unit via nurses Wechat groups (Wechat: an instant chat tool widely used in the workplace) with the help of nursing administrators from the six teaching hospitals. Individuals can choose whether or not to participate in this study without any obligation before completing the questionnaire. Informed consent forms are presented and must be signed by the participants. All questions are mandatory; the questionnaire cannot be submitted if any questions are left unanswered. The questionnaire was launched on 30 December 2020, 0:00, and closed on 31 December 2020, 24:00. The descriptions were given a number, such as O01.

Data analysis

According to Corbin and Strauss's (1990) theory, the transcripts from the interview and descriptions from the questionnaire were analysed based on the following coding procedures: (1) open coding, (2) axial coding and (3) selective coding. Figure 1 presents the data collection and analysis process.

FIGURE 1

Data collection and analysis process

As soon as the first bit of data was collected, the data from the interview were coded. At the open coding stage, the transcripts were conceptualized and then clustered into subcategories during the coding stage. Researchers analysed the subcategories and explored the relationship to develop main categories at the axial coding stage. And at the selective coding stage, the interrelationship among main categories had been further interpreted to form the core categories. To ensure that the core categories can explain all of the main categories, they should be closely related (Corbin & Strauss, 1990; Kempster & Parry, 2011). To avoid bias and achieve greater precision during the coding process, constant comparisons were used while analysing the data.

To improve trustworthiness and credibility, the survey data were coded and constantly compared with the data from the interview after homogeneous categorization. Furthermore, before coding the survey descriptions, they were screened against the following criteria: (1) The descriptions were clear; (2) the leaders' behaviours or traits were demonstrated; and (3) the descriptions were pertinent to the topic. The first and second authors completed this process and integrated similar descriptions for further analysis. Microsoft Excel 2021 software was used to screen and integrate the original descriptions from questionnaires.

Researchers repeatedly read the transcripts and descriptions to ensure their familiarity and sensitivity to the data in case of missing important information. The first and second authors encode the original transcripts and descriptions separately during the coding stage and then compare the results until the codes are consistent. If there were coding disagreements, seek assistance from the corresponding author to make a final decision. QSR NVivo 11.0 software was used to analyse the transcripts and integrated descriptions.

Theoretical saturation

Theoretical saturation is essential for verifying the perfection of the theoretical model. Expert interview and expert verification were used for theoretical saturation test to ensure the integrity and reliability of the results. First, three experts related to this topic were interviewed and then coded the transcripts. After that, no new codes emerged when compared with previous codes. Second, the original data, codes and results were submitted to three experts for review, and the theoretical model was considered saturated without any objections from the experts.

Ethical consideration

Before starting this study, ethical approval was obtained from the researchers' affiliated university's ethical committee (Approval Number S137). Meanwhile, the interviewees were informed of the information of this study, and written or oral consent was obtained from participants before the formal interview. The person who completed the questionnaire was considered to have agreed to participate in this study about the open‐ended questionnaire survey.

FINDINGS

Ten nurse leaders and 11 nurse staff with a mean age of 38.14 were recruited for the interview; the management experience of nurse leaders ranged from 3 to 26 years. The range of work experience of nurse leaders was 14–36 years, and the nurse staff was 3–15 years. Table 1 presents the detailed characteristics of participants. And a total of 454 participants were recruited in the open‐ended questionnaire survey, including 168 nurse leaders and 286 nurses. Table 2 depicts the detailed characteristics of participants. A total of 3005 descriptions were collected during the online survey. After screening and homogeneous categorizing, 123 descriptions were retained for further analysis.

TABLE 1

Demographic data (N = 21 participants)

No.	Gender	Age	Degree	Position	Years of work	Years of management
L01	Female	44	Master	Head nurse	22	12
L02	Female	41	Master	Head nurse	23	12
L03	Female	45	Master	Head nurse	23	6
L04	Female	52	Doctor	Director of nursing	34	23
L05	Female	52	Master	Chief nurse	34	22
L06	Female	43	Master	Head nurse	21	3
L07	Female	42	Master	Head nurse	20	8
L08	Male	36	Master	Head nurse	14	6
L09	Female	51	Bachelor	Director of nursing	34	25
L10	Female	54	Doctor	Director of nursing	36	26
N01	Female	30	Master	Nurse	4	None
N02	Male	28	Master	Nurse	3	None
N03	Female	32	Master	Nurse	2	None
N04	Female	32	Bachelor	Nurse	10	None
N05	Female	34	Bachelor	Nurse	10	None
N06	Female	29	Bachelor	Nurse	7	None
N07	Male	29	Bachelor	Nurse	6	None
N08	Female	30	Master	Nurse	8	None
N09	Female	35	Bachelor	Nurse	13	None
N10	Female	37	Bachelor	Nurse	15	None
N11	Female	25	Bachelor	Nurse	3	None

TABLE 2

Demographic characteristics (N = 454 participants)

Characteristics	Nurse leader (n = 168)		Nurse staff (n = 286)
	Frequency (%)	Mean (SD)	Frequency (%)	Mean (SD)
Age		39.77 (5.83)		31.77 (5.71)
<30	0 (0.00)		108 (37.76)
30–40	95 (56.55)		155 (54.20)
40–50	65 (38.69)		18 (6.29)
≥50	8 (4.76)		5 (1.75)
Gender
Male	5 (2.98)		11 (3.85)
Female	163 (97.02)		275 (96.15)
Marital status
Unmarried	6 (3.57)		78 (27.27)
Married	158 (94.05)		204 (71.33)
Divorced	4 (2.38)		4 (1.40)
Widowed	0 (0.00)		0 (0.00)
Education
Bachelor's degree or above	164 (97.62)		264 (92.31)
Secondary or advanced diploma	4 (2.38)		22 (7.69)
Hospital level
Tertiary hospital	147 (87.50)		264 (92.31)
Secondary hospital	21 (12.50)		22 (6.69)
Position
Chief nurse	6 (3.57)
Chief head nurse	9 (5.36)
Head nurse	149 (88.69)
Years of work		19.20 (7.47)		9.99 (6.26)
<10	10 (5.95)		156 (54.55)
10–20	82 (48.81)		107 (37.41)
20–30	60 (35.71)		16 (5.59)
≥30	16 (9.52)		7 (2.45)
Years of management		8.20 (6.72)		None
<10	113 (67.26)		None
10–20	40 (23.81)		None
20–30	12 (7.14)		None
≥30	2 (1.19)		None

The framework of the caring leadership model emerged as a result of multiple levels of coding and constant comparison. The coding process is shown in Table 3. The model represented the core attributes of caring leadership, how caring leadership works and the possible influence of caring leadership, presented in Figure 2.

TABLE 3

Coding process of caring leadership model

Selective coding	Axial coding	Open coding
		Category	Concept
Benevolent to others	Kindness	Easy to get along with	Treat nurses friendly
			Blend in nurses
			Closely connected to nurses
		Sincere	Treat nurses with love heart
			Respect for commitment to nurses
	Maintain dignity	Privacy protection	Protect the secrets of nurses
			No discussion of nurses' private affairs
		Inclusive	Forgive of nurses' working mistakes
			Allow nurses to make mistakes in their work
		Protect self‐esteem	Not just blaming the nurse for work mistakes
			No public criticism of nurses
			Consider the reputation of nurses
	Sensitive	Empathy	Understand the thoughts of nurses
			Consider things from nurses' perspective
			Consider the feelings of nurses
			Know the thoughts of nurses
			Consider practical conditions of nurses
			Explain the purpose and meaning of the work
		Considerate	Be proactive about nurses' lives
			Sensitive to the discomfort of nurses
			Sensitive to the needs of nurses
			Remember important days for nurses
	Work–life balance	Solve life challenges	Provided advice to nurses on solving life problems
			Help nurses dealing with life difficulties
		Meet family role	Rational scheduling based on nurse needs
			Scheduling support in case of emergencies
			Leave nurses alone out of working hours
	Improve health	Improve psychological health	Relieve work stress
			Help nurses to improve negative emotions
		Improve physical health	Help nurses to relieve physical discomfort
			Provide care for nurses when they are ill
Appreciate the uniqueness	Appreciate	Allow diversity	Respect nurses' personal values and beliefs
			Tolerate nurses with different personalities
		Inspire	Recognize the work of nurses
			Praise nurses for their achievements
		Know the right people	Identify the strengths of nurses
			Utilize nurses' strengths
	Trust	Openness	Communicate with nurses about their work
			Listen to nurses' opinions and suggestions
			Adopt nurses' opinions and put them into practice
		Empowerment	Allow nurses to participate in the unit management
			Allow nurses to solve problems with their judgment
Facilitate self‐actualization	Guide	Career development	Assist nurses with career development planning
			Advise nurses on their career development
			Provide opportunities for nurses' career development
		Career values	Provide career development direction for nurses
			Provide resources for nurses' career development
	Assist	Work support	Assist nurses in resolving work‐related difficulties
			Provide guidance and assistance in the work process
		Opportunity creation	Create opportunities for the professional development
			Seek career development opportunities for nurses
Maintain mutual benefits	Keep impartiality	Maintain interests	Ensure the safety of nurses in practice
			Protect the rights of nurses
			Promote the welfare of nurses
		Fairness and impartiality	Treat nurses equally
			Evaluate merits and awards fairly and equitably
			Fair performance appraisal
	Improve relationship	Build harmonious relationship	Sense of teamwork
			Promote collaboration
		Handle relationships well	Moderate interpersonal conflict
			Assist nurses in resolving interpersonal conflicts at work
	Shape environment	Shape organisational culture	Create a positive working atmosphere
			Organise team culture‐building activities
		Improve working environment	Improve the resting environment for nurses
Motivate with charisma	Charm of character	Devotion to duty	Expertise in nursing
			Possesses well‐organised management ability and skills
			Continually learning
			Enthusiastic about nursing
			Devoted to nursing
		Selflessness	Selfless in the work
			Do not care about personal gains and losses
			Do not rob nurses' achievements
		Modelling	Lead by example at work
			Act as a role model for nurses
			Have principles in the management of nurses
			Exhibit the right values
		Calm and decisive	Has good emotional control
			Handle work affairs decisively
			Make immediate decisions with unexpected situations
		Responsible	Share the suffering of nurses
			Accompany nurses in difficult situations
	Create the future	Visionary	Have a broad perspective of future
			Guide the direction of professional development
		Drive for change	Skilled in learning
			Have a sense of innovation

FIGURE 2

Caring leadership model

The attributions of caring leadership

Benevolent to others

Benevolence to others means nurse leaders treat nurse staff with love and kindness, keep authentic and inclusive, maintain their dignity proactively and are willing to provide support beyond working affairs to help nurse staff maintain a work–life balance and promote their physical health and psychological well‐being. In Chinese culture, leaders are often expected to play a paternalistic role; the benevolence of nurses embodies the leaders' concern for nurses' life and dignity so that nurses' non‐work needs can be met to some extent. Conversely, while there is an emphasis on the leader's authority in traditional leadership, in which staff needs to demonstrate absolute obedience to the leader, leaders' benevolence enables nurse staff to maintain a relatively close psychological distance from the leader, resulting in nurses' better work experience. During this process, a positive interpersonal relationship is built between nurse leaders and nurse staff, laying the foundation for leadership effectiveness.

A nurse said: ‘The head nurse has a genuine concern for us, she is always considerate of us in our daily lives, and we are not so nervous when we are with her … she helps us find a doctor or gives us a rest when we are not feeling well.’

Appreciate the uniqueness

Both nurse leaders and nurse staff believe that there are differences among nurse staff; thus, the diversity of individuals should be considered. Nursing leaders respect nurse staff's personalities and values, identify and develop nurse staff's strengths, fully trust and empower them, and recognize and appreciate their work and achievements. The appreciation of individuals' uniqueness contributes to an inclusive organisational climate, encouraging staff to be creative in their work and providing the conditions for innovation and organisational transformation.

A nurse leader shared: ‘It is important to develop the potential of the nurses, and then let them work on their own so that they can develop their own niche areas of interest … when a nurse wins a competition, I publicly praise them in the group and sometimes give them a small extra reward.’

Facilitate self‐actualization

Professional development is essential for the majority of the nursing staff. Nurses who are stuck in their professional development can experience burnout and lose enthusiasm for their work. By guiding the direction of nurse staff's professional development and providing assistance within their capacity, nurses' professional competence and work enthusiasm will improve. During this process, nurse staff will achieve professional growth and development, thus contributing to patient care quality. Moreover, the nurse's identification with the organisation will also be further strengthened.

A nurse leader said: ‘I held an offline meeting for nurses in 5 years, I first gave them a 5‐year plan and did a career planning motivation session … the nurses are allowed to further training and academic conferences.’

Maintain mutual benefits

Maintaining mutual benefits means the nurse leaders keep impartial, concerned about nurse staff's welfare, deal with interpersonal conflicts, strengthen cooperation and create a positive organisational environment, providing a holistic perspective on leaders' caring. The caring leader emphasizes the significance of developing positive interpersonal relationships with followers, which are not unique but universal. Those leaders should keep equality while treating the followers, and this impartiality helps in protecting the interests of all followers. Taking concern about the rights and interests of followers is an essential requirement of leaders' caring; the ignorance of followers' rights and interests leads to uncaring feelings. Promoting teamwork, resolving conflicts within the organisation and shaping a positive organisational working environment provide a managerial perspective on leaders' caring behaviours for the followers. All individuals in the organisation, other than the nurses, will benefit from these caring behaviours. On the one hand, nurses must collaborate with others at work. Promoting teamwork and resolving interpersonal conflicts contribute to collaboration, which results in high work efficiency. Conversely, improving the working environment is beneficial to the nurses' work experience and contributes to all individuals within the organisation. These elements demonstrate leaders' efforts to maintain the benefits of all individuals while considering nurses' interests. Leaders must also ensure that mutual benefits are maintained from an organisational perspective. Maintaining mutual benefits improves the cohesion between nurse staff, promoting the collaboration of nurse staff to achieve the organisation's goal.

A nurse said: ‘She must be concerned about the rights and welfare of nurses, and sometimes we want her to deal with the conflicts with others without favoring … she organizes some team activities to promote the collaboration.’

Motivate with charisma

Leaders' charisma refers to leaders' characters and competencies while accomplishing organisational goals and leading the organisation to excellence. Leaders' characters embody the followers' moral expectations, such as devotion, selflessness and modelling. Leaders competencies are related to the organisational existence and development, such as vision and creation. With the characters and competencies, leaders will set a model for followers while achieving organisational goals. During this process, followers will strengthen their inner identity and follow the leader to create a bright future. From the followers' perspective, the leader's good character and competencies satisfy their expectations of the leader's image, motivating them to follow the leader and reinforcing their positive work behaviours. Furthermore, a leader who neglects the characters and competencies requirement means their neglect of leaders' responsibilities, making it difficult to form an identity with the followers. The caring for the followers will remain superficial because of their inability to address the difficulties faced by followers, which is not conducive to the long‐term development of the organisation and the continuous caring of the followers. As a result, charming personalities and competencies of nurse leaders ensure the leadership process and the achievement of the organisation's goals, motivating nursing staff to strengthen their role behaviours and excellent performance.

A nurse leader shared: ‘The leader must set an example for everyone, so that they will trust you … and as a leader, you should lead ahead to reach a high goal, requiring you to be strategic and innovative.’

Work of caring leadership

Caring and leading are two ways that caring leadership works, and they are mutually reinforcing and cannot be separated. During the leadership process, nurse leaders should show respect, provide support, build mutual‐trust relationships with their staff, promote cooperation and meet future challenges. At the same time, nurse leaders must accept the responsibility and mission of being a leader in caring for their employees by guiding the direction of the organisation and the nursing staff, setting a good example for them and finally leading them to a bright future. When a leader focuses on caring while neglecting his or her responsibilities, the organisation's principles are violated, resulting in a loss of motivation and an inability to achieve the set goals. On the other hand, if a leader focuses on the organisation's tasks while neglecting to care for the staff, the staff will be unable to form a sense of belonging and will lose their creativity. Long term, it will jeopardize the organisation's development and excellence and the care for nursing staff.

A nurse leader shared: ‘Caring for nurses is very important, but the leading of nurses is also critical, the responsibility of leader requires the leader to be able to have long term goals that will bring the staff to further future.’

The consequences of caring leadership

Nurse well‐being

Nurse well‐being can be viewed as a direct result of caring leadership, implying that nurses have a positive working experience. With caring leadership, nurses will feel supported in achieving work–life balance and dealing with workplace challenges, increasing their job satisfaction. Moreover, nurses will also feel respected and trusted to maintain dignity and empowerment, enhancing their work performance, and they can realize self‐worth during this process.

A nurse said: ‘When I feel the concern of the head nurse, I feel warm and want to do a better job.’

Patient healing

Patient healing is one of the possible outcomes of caring leadership. Nurses who are caring will provide care to patients, which improves the patients' experience of nursing care. Furthermore, caring leadership influences the working behaviours of nurses, such as work engagement, which helps to improve the quality of patient care.

A nurse leader shared: ‘Nurse will take the responsibility to care for the patients and help them, which is more beneficial to patients' recovery and healing.’

Organisation excellence

Organisational excellence is viewed as the consequence of caring leadership as well. The collaboration of nurse staff can improve work efficiency, which helps decrease running costs and enhance health care quality. Furthermore, nurse staff will be positively motivated by the caring leadership of nurse leaders and will devote themselves to nursing care service, which is critical for organisational excellence.

A nurse said: ‘Nurse leaders with caring leadership will develop a good reputation of the organization so that individuals will want to work here and the hospital will develop well.’

DISCUSSION

This study used interviews and open‐ended questionnaires among nurse leaders and staff to develop a caring leadership model, making the results more reliable. The data integration resulted in three domains for the caring leadership model: (1) the core attributions, (2) the work way and (3) the consequence. It reveals nurses' perception of caring leadership in China, how caring leadership works in health care organisations and the possible consequences of caring leadership. According to this model, leaders establish a positive interpersonal relationship with nurse staff through caring and leading nurses with personal charms. Compared with previous studies, the caring leadership model in this study is developed through grounded theory rather than conceptual exploration (Bondas, 2003; Williams et al., 2011), it provides a view of caring leadership in Chinese culture and it reveals the working way and consequence of caring leadership in the leading process, helping to give rational thinking to nursing leaders.

Caring leadership focused on individuals' needs, existence and values and emphasized treating others with love and kindness to maintain an individual's dignity. For example, Bondas's (2003) study explored five elements of caring in nursing administration, such as valuing human dignity, recognizing employees' uniqueness and potential and organising with the caritas motive. Williams et al. (2011) described caring leadership model with the core values like always leading with kindness, compassion and equality, generating hope and faith through co‐create, embodying an environment of caring–helping–trusting for self and others, which are consistent with the core attributions like benevolent to others, appreciate the uniqueness and facilitate self‐actualization in our study. This level of consistency reflects the universality and understanding of the philosophy and ethics of care. However, the present research reveals two new attributions of maintaining mutual benefits and motivation with charisma; these two dimensions complement the requirements for effective caring leadership in organisations, emphasizing the importance of leaders in maintaining long‐term organisational stability and leading nurse staff to organisational excellence. Furthermore, in Chinese culture, leaders' responsibilities and morality were emphasized; these emerging two dimensions embody the Chinese nurses' unique understanding of caring leadership. The emphasis on caring for employees in health care organisations should not overshadow the leaders' responsibility and value (Levay & Andersson Bäck, 2021). When caring for nursing staff, leaders should maintain the mutual benefits of all stakeholders and motivate them with unique personal charisma, forming an excellent organisational culture and order. Caring leadership can achieve employee‐driven and organisational goals indefinitely under this condition.

Some popular leadership models currently include reference to leaders' caring and concern to individuals, such as individualized consideration in transformational leadership (Fischer, 2016) and benevolent leadership in paternalistic leadership (Chen et al., 2015). In China, nursing leadership also embodies caring human philosophy, highlighting nurse leaders' individual‐oriented caring to nursing staff in management. Relevant studies reveal that leaders' caring is essential in leadership, but the development and measurement of caring leadership were briefly discussed. In our study, the caring leadership model is developed as a specialized leadership, and caring leadership is expanded. For example, individualized consideration and benevolent leadership focus on caring for individuals' work and life (Chen et al., 2015; Fischer, 2016); our study reveals that a caring leader also pays attention to individuals' values, self‐actualization, benefits and family, reflecting the different understanding of caring in different cultural backgrounds. Furthermore, during the leadership process, leaders' duties and characteristics are emphasized, which aids in developing the individual's recognition of the leaders. As a result, leaders can influence and motivate individuals to help the organisation achieve its goals. Caring and leading are two essential processes of caring leadership in action. Previous research has primarily focused on the ethics and philosophy of caring, emphasizing caring for individuals without a leading process. In our study, the importance of leading is emphasized, for caring leadership, caring embodies the respect, love and kindness for employees, focusing on the existence of human beings, leading highlights the responsibility for employees, focusing on the version and future of all stakeholders, both of which are indispensable. For a caring leader, it is essential to be concerned with the mission of the organisation and the individuals (Levay & Andersson Bäck, 2021); the leading process helps develop a shared version and motivates the individuals to devote themselves.

In terms of the outcomes of caring leadership, this study is broadly consistent with previous research (Bondas, 2003; Brewer et al., 2020; Kostich et al., 2020). Caring leadership of nurse leaders improves nurses' experiences by reinforcing positive work behaviours, which contributes to the quality of patient care and the excellence of health care organisations. Meanwhile, the positive impact of patients and organisations positively impacts nurses. However, the results of this effect must be validated further through empirical studies.

LIMITATIONS

This study provides a framework for nurse leaders in Chinese health care institutions to understand caring leadership. To ensure reliability, researchers used a combination of methods to collect data. Because the caring leadership model is based on their perceptions and experiences, it has limited generalizability in other cultures, even Chinese culture has considerable influence in East Asia. Conversely, this study is a theoretical construct devoid of empirical evidence, requiring continuous revision and refinement with quantitative study design in future studies.

CONCLUSION

The present research provides a theoretical model of caring leadership in Chinese cultural background. The attributions reveal Chinese nurses' perspectives on caring leadership. The work of caring leadership indicates how to improve leadership efficiency, and the consequences present the influence of caring leadership in health care institutions. The results obtained from this study confirm the importance of caring leadership in health care institutions, which should be emphasized for nurse leaders. According to the study, caring leadership is further illustrated, and it provides a framework for future studies on measurement and leading practice.

IMPLICATION FOR NURSING MANAGEMENT

This caring leadership model developed in our study offers a new perspective and understanding of caring and leadership for nurse leaders. Nurse leaders need to strengthen their responsibilities and personal qualities while caring for nurse staff to improve leadership efficacy based on the theoretical model. Caring leadership can also assist nurse leaders in balancing the interests of all stakeholders, resulting in a positive outcome for nurse staff, patients and health care organisations.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ETHICS STATEMENT

The study was reviewed and approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (No. S137).