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The Contribution of Hospital Nursing Leadership Styles to 30-day Patient Mortality

Cummings, Greta G.; Midodzi, William K.; Wong, Carol A.; Estabrooks, Carole A.

doi: 10.1097/NNR.0b013e3181ed74d5

Background: Nursing work environment characteristics, in particular nurse and physician staffing, have been linked to patient outcomes (adverse events and patient mortality). Researchers have stressed the need for nursing leadership to advance change in healthcare organizations to create safer practice environments for patients. The relationship between styles of nursing leadership in hospitals and patient outcomes has not been well examined.

Objective: The purpose of this study was to examine the contribution of hospital nursing leadership styles to 30-day mortality after controlling for patient demographics, comorbidities, and hospital factors.

Methods: Ninety acute care hospitals in Alberta, Canada, were categorized into five styles of nursing leadership: high resonant, moderately resonant, mixed, moderately dissonant, and high dissonant. In the secondary analysis, existing data from three sources (nurses, patients, and institutions) were used to test a hypothesis that the styles of nursing leadership at the hospital level contribute to patient mortality rates.

Results: Thirty-day mortality was 7.8% in the study sample of 21,570 medical patients; rates varied across hospital categories: high resonant (5.2%), moderately resonant (7.4%), mixed (8.1%), moderately dissonant (8.8%), and high dissonant (4.3%). After controlling for patient demographics, comorbidities, and institutional and hospital nursing characteristics, nursing leadership styles explained 5.1% of 72.2% of total variance in mortality across hospitals, and high-resonant leadership was related significantly to lower mortality.

Conclusions: Hospital nursing leadership styles may contribute to 30-day mortality of patients. This relationship may be moderated by homogeneity of leadership styles, clarity of communication among leaders and healthcare providers, and work environment characteristics.

Greta G. Cummings, PhD, RN, is Professor, Faculty of Nursing, and Connecting Leadership Education and Research (CLEAR) Outcomes Program; and William K. Midodzi, PStat, PhD, is Post Doctoral Fellow, Faculty of Medicine, and Epidemiology Coordinating and Research Centre, University of Alberta, Edmonton, Canada.

Carol A. Wong, PhD, RN, is Associate Professor, Faculty of Nursing, University of Western Ontario, London, Canada.

Carole A. Estabrooks, PhD, RN, is Professor and Canada ResearchChair, Knowledge Translation, Faculty of Nursing, and Knowledge Utilization Studies Program, University of Alberta, Edmonton, Canada.

Editor's Note Materials documenting the review process for this article are posted at and

Accepted for publication May 26, 2010.

This study was supported by a New Investigator Award (Canadian Institutes of Health Research) and a Population Health Investigator Award (Alberta Heritage Foundation for Medical Research) to Dr. Greta Cummings, a Canada Research Chair award to Dr. Carole A. Estabrooks, and an operating grant from the University of Alberta Small Faculties grants.

Corresponding author: Greta G. Cummings, PhD, RN, Faculty of Nursing, University of Alberta, 5-134 Clinical Science Building, Edmonton, Alberta, Canada T6G 2G3 (e-mail:

© 2010 Lippincott Williams & Wilkins, Inc.