NURSE LEADERSHIP STYLE AND QUALITY OF CARE IN CLINICAL SETTING: A SYSTEMATIC REVIEW

Nowadays there are mounting concerns about leadership style because of its critical role in job satisfaction and the quality of care of patients. To explore different of leadership style to improve quality of care in healthcare setting upon empirical literature published in the last ten years. Literature review. A comprehensive electronic database search was conducted in PubMed Web of Science, CINAHL, Embase to retrieve relevant articles published in English from January 2011 until January 2021. Key terms and phrases associated with leadership style, quality of care and nurses. The abstracts or full texts of research papers were reviewed prior to their inclusion in the review. A total of 18 papers were included in this review. There are thirteen articles using transformation leadership style, and the other are transactional leadership style and autocratic leadership style, passive avoidant and resonant leadership style. The impact of leadership style to improve quality of care in decreasing cost, increasing patient satisfaction, and patient safety has been identified in a number of research studies. Leadership style is closely related to quality of care, extra effort, effectiveness, job satisfaction, organizational commitment, staff intention to stay, inspirational motivation, general health well being, sex, age, educational background and nurses' assigned unit. Various mediating or moderating pathways have been identified with leadership style and quality of care such as work environment, structural empowerment, organizational commitment and job satisfaction. It is vital to choose effective leadership style because this has the potential both to improve quality of care and ensure an adequate nursing workforce. The indirect relationships and predictors of leadership style and quality of care contribute to a more comprehensive understanding of the complex phenomenon of leadership style which in turn may aid the development of effective strategies to address the nursing shortage and increase the quality of patient care.

al, 2018; Asif et al, 2019). Zaghini et al (2019) also found that when nurses were satisfied with leadership, they felt less wore out and stressed in relational connections, they connected less in misbehaviour, and, thus, patients were increasingly satisfied with the quality of the care given by the nurses. Contrary study came from Iran (Bahadori et al., 2016) which reported that there was no relationship between leadership style and patient satisfaction.
Quality of care as defined by WHO (2016) as the extent to which health care services provided to individuals and patient populations improve desired health outcomes. To accomplish this, health care should be safe, effective, timely, efficient, equitable and individuals-centred. Quality of care as one outcome of nurse services in health care setting is also indicator of performance of nurses and their team. A nurse leader in that team have a big role to ensure they provide excellent quality of care for patients. A leader needs to choose leadership style that is appropriate to the resources in the ward or departement he/she lead. The organizational commitment of nurses results in lower attrition rates and improves patients satisfaction (Marshall et al., 2001). The organizational commitment of nurses are influenced by attitude and leadership style of the immediate supervisor.
Abisilim et al (2019) found that leadership style have significant relationship with age, marital status, academic qualification, employment status and year of service. Regarding of academic qualification, In Indonesia, based on data from Ministry of health, until December 2019 there were 376,136 nurses in Indonesia and majority their education background is 3rd Diploma (study nursing for 3 years in college). From many research in Indonesia, mentioned that leadership style they used were democratic leadership or authority leadership or mix leadership and a few is transformational leadership (Rahardjo, 2019;Roostyowati, 2017, Suratno, 2018. Study from New Zealand (Parr et al., 2020) found a new outcome related to leadership style. On their study, resonant leadership have significantly and positively reduced falls rate. Besides this study, the reason for the systematic review is to update the previous systematic review (Sfantou et al., 2017), which used articles from 2004 to 2015.
Inclusion criteria were: nurses working in hospitals or healthcare setting, published in English, address on one of leadership style, publish between 2011 to 2021. Exclusion criteria were: population is student nurses, nurse assistants and other health provider. We limited the work setting with inpatient ward because nurses working in these areas are frequently given with complex nursing decisions, long hours, shift work and rapid patient turnover (Hayes et al., 2010).
After found article based on keywords, all articles were exported to Endnote X9 and the duplicates were removed. This step identified a total of 3301 published research papers from all the databases searched. The next step was screened for eligibility and relevance based on titles and abstracts. If title or abstract did not gave adequate information or if a final decision could not be made, we evaluated the full article. After screening process, papers that did not meet the inclusion criteria were removed. Disagreements happening in KMC selection procedure were resolved by discussion in order to reach a consensus. Finally, only 19 paper that included in this review ( Figure 1). Testing quality of articles used appraisal from The Joanna Briggs Institute (JBI) for cross sectional study, cohor study (longitudinal) and qualitative study.

The Type of Leadership Style Among Nurse
From eighteen articles which reviewed, nurse leaders use directive (autocratic) leadership style, supportive (transformational) leadership style, participative (democratic) leadership style, achievement-oriented (transactional) leadership style, resonant leadership style, ethical leadership style, laissez-faire leadership style and passive avoidan leadership. Thirteen articles mention about transformational leadership style in their article. Alloubani et al (2018) found that the private hospitals prefer use the transformational leadership while the public hospital prefer transactional leadership.

Influencing Factors of Leadership Style
Beside the effects of leadership style on nurse quality of care, it also have impact in job satisfaction, extra effort, effectivenes, organizational commitment, staff intention to stay, inspirational motivation, general health and well being.

Quality of Care
Regarding the effect of leadership style on quality of care, there were some similar findings in the different studies. Recent study from Ngabonzima et al (2020) reported service provisions indicated a positive relationship with four leadership style (directive leadership style, supportive leadership style, participative leadership style and achievement oriented leadership style), but more with directive leadership style than others (mean 18.8, SD 0.730). Service provision measured quality of service provided to the patients, commitment of the colleagues in provision good health service, commitment to provide better quality of service, and satisfaction of the patients. From four items above, highest mean reported is commitment to provide better quality services (mean 4.14).
Another study from Alloubani et al (2018) showed there was a significant positive relationship among the transformational leadership and quality of nursing care (r= 0.87; p <0.001). There was a significant negative correlation between transactional leadership with quality of nursing care (r=-0.22; p <0.001). Additionally, there is no significant relation-  Correlation among TL, SE, JS, and QOC are positive & significant, but the correlation of TL, SE, JS and QOC with APO are significant negative. TL is positively related to nurses'JS (r= 0.43, ß = 0.37, t = 7.71 p < 0.01) TL is positively related to SE (r= 0.38, ß = 0.41, t = 8.72 and p < 0.01), SE is positively related to nurse-assessed QOC (r= 0.41, ß = 0.43, t = 8.96 p < 0.01), JS is positively related to nurseassessed QOC (r= 0.36, ß = 0.31, t = 6.08 p < 0.01). SE negatively related to APO & a negative association between SE and APO (r= -0.34, ß =-0.32, t = -6.53 p < 0.01). nurses' JS is negatively related to APO (r= -0.24, ß = -0.29, t = -6.04 p < 0.01) Nurses reported a moderate degree of transformational leadership in their managers (X = 2.05; SD = 0.99). Access to work environment factors that empower nurses to work effectively was slightly above the midpoint of the scale (X = 11.91; SD = 3.77; range, 4-20). Nurses reported that patient and/or family complaints (36%) and nosocomial infections (28%) occurred occasionally to frequently. On average, nurses were moderately satisfied with their jobs (X = 3.05; SD = 0.97) as 55% of nurses agreed or strongly agreed with statements regarding their satisfaction with the job. Transformational leadership had a strong and significant positive direct effect (b = 0.77; p < .001) on structural empowerment, had a positive effect on job satisfaction (b =0.86; p < .001), and a negative direct effect on adverse events (b =-0.35; p < .05). Transformational leadership significantly predicted quality of care score (b = 0.21, t(534) = 4.28, P < 0.0001) and abusive leadership practices negatively and significantly predicted quality of care scores (b = -0.13, t(534) = -2.62, P < 0.01). Transformational leadership negatively and significantly predicted the intention to quit the healthcare facilities scores (b = 014, t (349) = 234, P < 005) and abusive leadership positively and significantly predicted the intention to quit the health care facilities scores (b = 023, t(349) = 382, P < 00001. Abusive leadership posi-tively and significantly predicted the intention to quit the healthcare facilities scores (b = 026, t(352) = 444, P < 00001 There was positive, highly significant correlation between outcome factors (effectiveness, extra efforts, satisfaction) and transformational, transactional leadership styles, negative significant correlation with laissez-faire leadership style. There were significant differences between male, female nurses in regards to using transactional leadership style, laissez-faire leadership style with male nurses mean score higher than female nurses mean score in both styles (transactional style: male, female; laissez-faire leadership style: male, female). Regarding nurses' educational level, length work in nursing, there were no significant differences between nurses' perceptions leadership styles, factors, outcomes. Regarding differences related to nurses' assigned unit, there were significant differences in transformation leadership style, transactional leadership style post hoc analysis showed nurses working in medical-surgical units have almost lower perception all leadership outcome factors than nurses working in oncology, critical care, other units at hospitals ship between laissez-faire and quality of nursing care (r=-0.04; p <0.645). Slightly different findings came from Asif et al (2019), reported that transformational leadership have a significant relationship with structural empowerment (alpha = 0.57; p <0.01), and structural empowerment have a significant relationship with quality of care (alpha = 0.39; p <0.01). Also transformational leadership have a significant relationship with job satisfaction (alpha = 0.43; p <0.01), and job satisfaction have a significant relationship with quality of care (alpha = 0.23; p <0.01).
Study of Lotfi et al (2017) to determine the relationship between ethical leadership, organizational commitment of nurses and their perceptional of patient safety also reported that there was a positive relationship between ethical leadership and perception of patient safety culture (r = 0.29; p <0.001). A different finding reported by Bahadori et al (2016) which show that there was no significant relationship between leadership style (transformational and transactional) and patient satisfaction. However, the highest satisfaction level (3.52 ± 0.63) of the patients was reported in the wards whose head nurses used a transformational leadership style. Study from Parr et al (2021) showed that resonant leadership reduced falls rates (alpha = 0.14, p <0.05). Similar study from Finland (Lappalainen et al., 2019) showed that transformational leadership have significant relationship with medication safety. It was also similar from USA (Faraq et al, 2017) which reported Transformational leadership have significant relationship with safe medication.

Extra Effort
Alloubani et al (2017) showed there was a significant positive relationship among the transformational leadership and extra effort (r= 0.76; p <0.001). There was a significant negative correlation between transactional leadership with extra effort (r=-0.32; p <0.001). Additionally, there is no significant relationship between laissez-faire and extra effort (r=-0.04; p <0.912). Slightly different findings came from Aboshaiqah et al(2014), reported that extra effort of their supervisors' leadership style are fair. The analysis showed that nurses had fair perception in regards extra efforts (M= 2.69, SD = 0.97). Nurses had fair perception of the expected outcome of their supervisors' leadership style.
The 7 the transformational leadership and effectiveness (r= 0.79; p <0.001). There was a significant negative correlation between transactional leadership with effectiveness (r=-0.26; p <0.001). There is no significant relationship between laissez-faire and effectiveness (r=0.08; p <0.912). This findings also similar to study from USA (Faraq et al., 2017) that mentioned transformational leadership style associated with effectiveness. A different findings came from Aboshaiqah et al (2014), showed that effectiveness of their supervisors' leadership style are fair. The analysis showed that nurses had fair perception in regards extra efforts (M=2.92, SD = 0.91). This results indicate nurses had fair perception of the expected outcome of their supervisors' leadership style.

Job Satisfaction
Recently Ngabonzima et al. (2020) conducted a cross-sectional in Rwanda, and found that directive leadership style, supportive leadership style, participative leadership style and achievement oriented leadership style have a positive significant with job satisfaction (r = 0.58, 0.52, 0.49,0.36; p <0.05). It was also similar to qualitative study from Iran (Barkhordari-Sharifabad et al, 2017). They reported that ethical leadership gave employee satisfaction. Slighly different study from Alloubani et al (2018) reported there was a significant positive relationship among the transformational leadership and job satisfaction (r= 0.81; p <0.001). There was a significant negative correlation between transactional leadership negative correlation between transactional leadership with job satisfaction (r=-0.38; p <0.001). Additionally, there is no significant relationship between laissez-faire and job satisfaction (r=-0.06; p <0.376). Similar findings came from Asif et al (2019), reported that transformational leadership have a significant relationship with job satisfaction (alpha = 0.43; p <0.01). Another similar findings also came from Lin et al (2015), which transformational leadership stily have a positive significant with job satisfaction (r= 0.48; p <0.01).

Organizational Commitment
Using cross sectional study Lin at al (2015) investigated the influences of nursing transformational leadership style on the quality of nurses' working lives in Taiwan, which transformational leadership style have a positive significant with organizational commitment (r= 0.32; p <0.01). Another study from Lotfi et al (2017) also showed that ethical leadership style have a positive significant with organizational commitment ( r = 0.21; p <0.001).

Staff Intention to Stay
Recent study from Ngabonzima et al (2020) reported directive leadership style and supportive leadership style have a positive relationship with staff intention to stay (r= 0.25, 0.15 p <0.01 and <0.05). Participative leadership style and achievement oriented leadership style have no significant relationship with staff intention to stay (r= 0.06, 0.08). This study quite similar from Canada (Laovioe-Tremblay et al., 2015) showed that transformational leadership style predict intention to quit. Contrary evidence came from Australia (Cheng et al., 2015) reported transformational leadership style have negative correlation with turnover intention.

Inspirational Motivation
Study of Faraq et al (2017) showed that in transformational leadership style, nurses perceived that their nurse manager displayed inspirational motivation attributes more often (mean (SD), 2.8 (0.7)) than the other attributes. This is similar with study from Iran ( Barkhordari-Sharifabad, et al, 2017) who reported ethical leadership inspire employees behaviour.

General Health Well-Being
Lin et al (2015) on their research found that transformational leadership style have a negative significant with general health well-being (r= -0.15; p <0.01). The scores were significantly higher in private hospitals (M = 15.07, SD = 5.00) which revealed the worse health status.
Mediators between leadership style and quality of care among nurses The direct effects of various factors influencing leadership style and quality of care have been verified but the indirect effects have yet to be identified. While trying to fill the gap, mediation analysis and pathway analysis are being used diation analysis and pathway analysis are being used by growing numbers of researchers to recognize and clarify different pathway. From some researcher found that work environment, supervisor support, structural empowerment and job satisfaction are mediators between leadership style and quality of care.

Work Environment
Study of Suratno et al (2018) in 5 type of hospital in Indonesia (military hospital, police hospital, public hospital, private hospital, and teaching hospital) found that transformational leadership style have a positive significant relationship with work life (r= 0.27 at p value <0.01).

Structural Empowerment
Study of Asif et al (2019), reported that transformational leadership have a significant relationship with structural empowerment (alpha = 0.57; p <0.01), and structural empowerment have a significant relationship with quality of care (alpha = 0.39 ; p <0.01). So structural empowerment is mediator between leadership style and quality of care.

Organizational Commitment
Lin et al (2015), which transformational leadership style have a positive significant with supervisor support (r = 0.74; p <0.01), and supervisor support have a positive significant with job satisfaction (r= 0.52 at p value 0.01). Job satisfaction have a positive significant with organizational commitment (r = 0.56; p <0.01). From Lotfi et al (2017) study found that leadership style have a significant relationship with organizational commitment. Based on that, organizational commitment is mediator between leadership style and quality of care.

Job Satisfaction
Study of Asif et al (2019), transformational leadership have a positive significant relationship with job satisfaction (alpha = 0.43; p <0.01), and job satisfaction have a significant relationship with quality of care (alpha = 0.23 ; p <0.01). Job satisfaction is mediator between leadership style and quality of care.

DISCUSSION
Effective leadership in health services has already been extensively studied in the literature, but it mostly come from developed country. Not much research is published from developing countries, especially quantitative research in last 10 year. Many challenges have found the urgent need for effective leadership styles in health services (Schreuder, 2011). The current literature review endeavored to fill this gap, while it figured out how to distinguish the latest publication to evaluate the relationship between leadership style with quality of care.
Among the main findings reported that the quality of service received by patients in the form of satisfaction, safety, and cost (Alloubani, 2018;Bahadori,2016). This finding is consistent with recent study which transformational leadership have a positive relationship with safety climate in hospital (Merril et al, 2015). Passive-avoidant leadership style have relationship with nurses' willingness to report medication error, and transactional leadership style have relationship with safe medical administration. Similar finding also came from Zaghini et al (2020), counter productive work behaviour and depersonalization were linked to patient satisfaction. A investigation of Canadian nurses, Higgins (2015) also found that nurses' perceptions of their managers' transformational leadership behaviors had negative effects on equitably estimated adverse events (i.e., patient falls and hospital infections) through supportive practice environments and organizational citizenship behaviors.
From all literature which review in this article, mostly using transformational leadership style, participate leadership style and transactional leadership style. This condition is influenced by the level of education, work experience, age and length of work in the current work unit of nurses leader. Many of them graduate from diploma, were young (22-40 years old), experience below five years and working in current unit below five years (Ngabonzima, 2020;Asif, 2019;Suratno, 2018;Alloubani, 2017;Olu-Abiodun, 2017;Lotfi, 2017;Bahadori, 2016). Previous study reported that age, education background and year of experience in current unit have positive significant with leadership style (Abasilim, 2019;Yoon, 2016). Graduate level of education has good leadership knowledge. Likewise, the maturity of the age and length of work in the unit enable to think logically in choosing the appropriate type of leadership. The combination of the three makes it possible to produce nurse leaders who are able to improve the quality of care.
Furthermore, increased quality of care in healthcare settings has been found to be closely related to transformational leadership style and transactional leadership style (Asif, 2019;Allouboni, 2017;Bahadori, 2016).For instance, transformational leadership and transactional leadership increases nursing unit organization culture and structural empowerment [Asif, 2017]. This has an impact on organizational commitment for nurses and in return higher levels of job satisfaction, intention to stay, quality nursing work life , general health well being patient safety and quality of care (Ngabonzima, 2020;Asif, 2019;Suratni, 2017;, Bahadori, 2016. In transformational leadership nurse's leader motivate nurse to achieve the goals as yet never achieved before, give attention for nurse, able to train, and make nurse loyal to her/his unit. In transactional leadership, nurse leaders exchanging followers who lead to improvement in production, and are interested in processes rather than shared values with forward-thinking. In Transcactional leadership also offering rewards for attractive satisfaction and retaining incentives for poor outcomes (Boldy et al, 2013).
Those article in this review vary from developed to developing countries with sizeable sample size ranging from 262 to 3182, from rural hospital to urban hospital. In addition, this article also finds a new outcome of leadership style and quality of care, namely reduced falls.
Although this review have such strenght above, it also have some limitation. This review mostly come from cross sectional study which is can not explain how those outcome of leadership style change after a period of time. Beside that, the article included in this review only in English.

CONCLUSSION
Transformational leadership style is effective leadership to improve quality of care in hospital in developing country or and country in Asia, Africa and South American region. With a limited number of professional nurses capable of being leaders, it is necessary to consider update leadership training in hospitals. In addition, director of hospital encourage their nurse staff to pursue their degree to high level nursing education.