Nurse leaders as problem-solvers: Addressing lateral and horizontal violence : Nursing Management

problem solving nursing leadership

  • Subscribe to journal Subscribe
  • Get new issue alerts Get alerts

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

Nurse leaders as problem-solvers

Addressing lateral and horizontal violence.

Anthony, Michelle R. PhD, RN; Brett, Anne Liners PhD, RN

Michelle R. Anthony is a program coordinator at Columbia (S.C.) VA Health Care System. Anne Liners Brett is doctoral faculty at the University of Phoenix in Tempe, Ariz.

Acknowledgment: The authors acknowledge the support of the University of Phoenix Center for Educational and Instructional Technology Research.

The contents of this article do not represent the views of the US Department of Veterans Affairs or the United States Government.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

For more than 126 additional continuing-education articles related to management topics, go to .

Earn CE credit online: Go to and receive a certificate within minutes .

Read about a qualitative, grounded theory study that looked to gain a deeper understanding of nurse leaders' perceptions of their role in addressing lateral and horizontal violence, and the substantive theory developed from the results.


The issue of lateral and horizontal violence (LHV) has plagued the nursing profession for more than 3 decades, yet solutions remain elusive. The significance of LHV isn't lost on nurse leaders because it creates an unhealthy work environment. Research literature worldwide has continued to report the prevalence of disruptive behaviors experienced by nursing students, novice nurses, and seasoned nurses in the workforce. The World Health Organization, International Council of Nurses, and Public Services International have recognized this issue as a major global public health priority. 1

LHV, also called nurse-on-nurse aggression, disruptive behavior, or incivility, undermines a culture of safety and negatively impacts patient care. 2,3 This experience, known to nurses as “eating their young,” isn't only intimidating and disruptive, it's also costly and demoralizing to the nursing profession and healthcare organizations. 4,5 Although the impact of LHV can be dreadful for both the institution and its staff, little is known about the reasons for these behaviors among nursing professionals. 2

LHV encompasses all acts of meanness, hostility, disruption, discourtesy, backbiting, divisiveness, criticism, lack of unison, verbal or mental abuse, and scapegoating. 6 The sole intent of bullying behaviors is to purposefully humiliate and demean victims. Bullying behaviors also taint healthcare organizations; cause irreparable harm to workplace culture; breakdown team communication; and severely impact the quality of the care provided, thereby jeopardizing patient safety. 7,8 Researchers have reported that acts of LHV are used to demonstrate power, domination, or aggression; for retribution; to control others; and to enhance self-image. 9-12

Previous studies have shown that the frequency of LHV in healthcare organizations is quite severe, with about 90% of new nurses surveyed reporting acts of incivility by their coworkers. 13 Sixty-five percent of nurses in one survey reported witnessing incidents of despicable acts, whereas another 46% of coworkers in the same survey reported the issue as “very serious” and “somewhat serious.” 13

LHV poses a significant challenge for nurse leaders who are legally and morally responsible for providing a safe working environment. 2,6 The purpose of this qualitative, grounded theory study was to gain a deeper understanding of nurse leaders' perceptions of their role in addressing LHV and develop a substantive theory from the results.

Literature review

A paucity of evidence exists in the literature regarding how nurse leaders perceive their role in addressing LHV. 14 Studies have shown that this phenomenon is attributed to heavy workloads, a stressful work environment, and lack of workgroup cohesiveness, as well as organizational factors such as misuse of authority and the lack of organizational policies and procedures for addressing LHV behaviors. 15

In one study, one-third of the nurses reported that they had observed emotional abuse during several of their work shifts. 16 Another study indicated that 30% of survey respondents (n = 2,100) stated LHV occurs weekly. 17 A third study revealed that 25% of participants noted LHV happened monthly, and a fourth study of ED nurses reported that about 27.3% of the nurses had experienced LHV perpetrated by nursing leadership (managers, supervisors, charge nurses, and directors), physicians, or peers in the last 6 months. 18

In a survey completed by members of the Washington State Emergency Nurses Association, 27% of respondents experienced acts of bullying in the past 6 months. 19 Another study reported that 27% to 85% of nurse respondents had experienced some form of uncivil behavior. 20 Other data have shown that those more vulnerable to violent, disruptive, and intimidating behaviors are newly licensed nurses beginning their careers. 21

Although nurse leaders can be perpetrators of LHV, they play an essential role in addressing LHV behaviors and creating a safe work environment. 22 The literature suggests that, in many cases, a lack of awareness and response by nurse leaders adds to the prevalence of LHV. 23 This may be due, in part, to nurse leaders being aligned with the perpetrators who are creating the toxic work environment. 6 The literature suggests that an environment where staff members feel safe to practice results in a culture that decreases burnout and promotes nurse retention and quality outcomes. 24,25

This qualitative, grounded theory study focused on nurse leaders' perception of their role in breaking the cycle of LHV for staff members whom they supervise. Two research questions guided the study: 1. How do nurse leaders perceive their role in addressing LHV among nursing staff members under their supervision? 2. What substantive theory may emerge from the data collected during interviews with nurse leaders?

A grounded theory methodology was used to explore the nurse leader's role in addressing LHV with the intent of developing a substantive theory through the meaningful organization of data themes to provide a framework to address the phenomenon of LHV. Purposive sampling was used to recruit a total of 14 participants for this study from a large healthcare system in the Southeastern US. The participants were chosen because of their experience with LHV and their ability to discuss and reflect on those experiences. Informed consent was obtained before the start of the study, which included explaining the reason for the study and what to expect. In addition, permission was obtained from the Institutional Review Board.

Data collection and analysis

Demographic data collected to describe the sample included gender, age range, number of years holding a management position, supervisory responsibility, and highest degree obtained. (See Table 1 .)


Semistructured, in-depth interviews were the primary mode of data collection. The recorded interviews were conducted face-to-face and lasted about 60 minutes. Data collection continued until saturation was achieved. Data saturation occurred when no new descriptive codes, categories, or themes were emerging from the analyzed data. The interviews were transcribed verbatim and verified through a member check process.

During the data analysis process, themes and patterns were identified. Data from each participant's interview were examined to determine if the responses were aligned with the identified themes. Analysis of the data included coding at increasingly abstract levels and constant comparison. Qualitative software assisted in coding the information and uncovering subtle trends.

Four themes emerged from core categories developed during the qualitative data coding process.

Theme 1: Understanding/addressing LHV . In question one, participants were asked to describe their understanding of LHV. Five subthemes emerged from the data collected with this question. (See Table 2 .)


Theme 2: Experience addressing LHV . In the second question, participants were asked about their experience with addressing incidents of LHV. Six subthemes were identified. (See Table 3 .)


Theme 3: Role perception in addressing LHV . In the third question, participants were asked what they perceive their role to be in addressing LHV. Six subthemes resulted from this question. (See Table 4 .)


Theme 4: Organizational impediment to addressing LHV . In question four, participants were asked to describe the factors within the organization that influence or impede their role in addressing LHV. This question yielded nine subthemes. (See Table 5 .)


Substantive theory

As a result of the themes that emerged from the data, a substantive theory was developed. This is especially important for the nursing profession to develop as a scientifically based practice. Theories help guide research and provide the expansion, generation, and validation of the science of nursing knowledge. 26 The substantive theory will help nurse leaders become more cognizant of the role that effective leadership plays in preventing or intervening in incidents of LHV in the workplace. The analysis revealed that nurse leaders are aware that the quality of patient care and staff well-being can be adversely affected by the impact of LHV.

Data themes were used to formulate the following theory: Nurse leaders address LHV affecting their staff members by solving problems, creating a safe work environment, and reducing institutional barriers that impede addressing LHV in a timely fashion. Nurse leaders perceive their role as a problem-solver, which is a necessary step in advocacy. 27 Problem-solving is a process that contains the elements of decision-making and critical thinking. 28

The theory that emerged from the core categories explicitly focused on the central phenomenon of LHV in the nursing work environment. Figure 1 shows the interrelatedness of the themes to the resultant substantive theory.


Discussion and implications

The study results have several implications for both the nursing profession and nurse leaders. The nursing profession requires decisive and robust leadership, and the role of the nurse leader is to be a combination of nurturer, investigator, and judge to examine incidents of LHV. 26,29-32 Nurse leaders are responsible for setting the tone and expectations for a safe work environment. This includes modeling the expected ethical behaviors; for example, doing the right things for the right reasons, being collegial toward each other, and being respectful of other's differences. One participant remarked, “This is a different world based on how I was raised. I was raised to be respectful to people.”

In addition, nurse leaders are responsible for enforcing policies created to address disruptive behaviors and working with the administration as soon as an incident occurs. Past research indicates that a healthy and collaborative work environment fosters nurse engagement and patient safety. 25,30 Staff members and patients need a leader to protect them when necessary; thus, the nurse leader needs to “walk the walk” in providing a safe environment for all. Nurse leaders engaged in these kinds of behaviors are providing strong leadership and practicing strong decision-making, thus ensuring the continued robustness of their organizations.

Recommendations and limitations

Future research could replicate this study in a different geographic region to explore the causes of LHV by soliciting the views of nursing students, new graduate nurses, and nurse educators from unionized and nonunionized hospital systems and comparing the results to further understand this phenomenon. Additionally, developing a tool to test the substantive theory could substantiate the nurse leader's role as a problem-solver to address incidence of LHV in the workplace.

The decision to conduct this study in one type of healthcare organization limits the ability to compare the interviewed nurse leaders' experiences with nurse leaders in other healthcare organizations. The experiences of nurses in other healthcare organizations may be different; thus, overall generalizability of the study may be limited.

Say “no” to the status quo

The results of this study support the findings of previous researchers. 23,31,33,34 Accepting the status quo is unacceptable and can cause irreparable harm to organizational well-being if LHV isn't addressed. Collaboration between nurse leaders and administrators is essential to successfully reduce institutional obstacles that prevent the timely handling of LHV incidents. The role of the nurse leader as a problem-solver should be clear, defined, and well supported to seek resolutions to toxic behaviors that are hurting the work environment. But we must remember that creating a policy doesn't equal change. Every employee from the lowest level in the organization to the highest ranks of administration must model civil behaviors.

INSTRUCTIONS Nurse leaders as problem-solvers: Addressing lateral and horizontal violence

Test instructions.


Lippincott Professional Development will award 1.5 contact hours for this continuing nursing education activity.

Lippincott Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 1.5 contact hours, and the District of Columbia, Georgia, and Florida CE Broker #50-1223.

Payment: The registration fee for this test is $17.95.

NSUOK Logo nursing online programs

Home » Degrees » RN to MSN » Registered Nurse to Master of Science in Nursing in Administrative Leadership in Nursing » How Leaders Approach Problem-Solving

How Leaders Approach Problem-Solving

No environment is free from problems. But, some require more creative solutions than others.

Healthcare, in particular, presents almost unlimited opportunities for things to go wrong — both in terms of patient care and inter-staff/intra-staff relationships. The problems present within healthcare settings are often a matter of life and death.

It takes effective leadership to keep all issues to a minimum and patient safety remains a priority.

What Makes a Great Leader?

If we think about the great leaders throughout time, they share a few common characteristics. Specific to nurse leaders, lists the following as core qualities for leaders:

Another valuable quality in leadership is being proactive in problem-solving. Good leaders handle issues as they arrive. They are capable of “putting out fires,” and that’s important. Yet, great leaders anticipate problems before they come to a head.

Core Skills Nurse Leaders Need to Possess

While some of the above resonates as more intuitive, emotional intelligence — as opposed to procedural — can be learned. Of course, there are practical skills nurse leaders need to develop as well.

Examples of these skills are healthcare finance and economics. Mastering budgets and efficiently allocating resources is important for nurse leaders. Nurses also need to know how to communicate financial demands to upper administration.

The online Registered Nurse (RN) to Master of Science in Nursing (MSN) in Administrative Leadership program from Northeastern State University (NSU) dedicates a course to heightening nurses’ skills and knowledge surrounding this responsibility.

NSU’s program also includes a course titled Organizational and Systems Management in Nursing. The course description states that nurses will learn about “contemporary influences, theories, principles, and functional strategies related to management/administration and organizational systems at the micro, meso, and macrosystem levels.”

Leadership’s Role in Addressing Lateral and Horizontal Violence (LHV)

While nurse leaders don’t necessarily need to be experts in human resources, it’s a substantial knowledge base. Human resources knowledge is especially relevant given the persistence of lateral and horizontal violence (LHV) within the nursing profession. The World Health Organization (WHO), International Council of Nurses and Public Services International have recognized this issue as a significant global public health priority.

Just how dangerous is LHV to nursing? A study published by Nurse Management describes LHV as: “all acts of meanness, hostility, disruption, discourtesy, backbiting, divisiveness, criticism, lack of unison, verbal or mental abuse, and scapegoating. [These] behaviors taint healthcare organizations; cause irreparable harm to workplace culture; breakdown team communication; and severely impact the quality of the care provided, thereby jeopardizing patient safety.”

With a solid leadership foundation, nurses can handle toxic behaviors that damage the work environment. In doing so, they change the workplace culture and guiding others to follow in their footsteps.

Empowerment Sets Everyone Up for Success

Perhaps the greatest responsibility of a nurse leader is to empower those in their charge. John Quincy Adams said, “If your actions inspire others to dream more, learn more, do more and become more, you are a leader.”

Northeastern State University recognizes empowerment as an essential skill. In the Leadership Development for the Advanced Nursing Professional course, students learn to “effectively manage change, empower others, and influence political processes.”

What Type of Leader Do You Aspire to Be?

It takes much more than “putting in your time” to become an effective leader. Nurses might rise through the ranks based on experience, but are they actually effecting change in the nursing profession? Unless they possess a robust leadership skill set, the answer is likely no. So, what kind of leader do you want to be?

Learn more about Northeastern State University’s online RN to MSN in Administrative Leadership program .

Related Articles

Our commitment to content publishing accuracy.

Articles that appear on this website are for information purposes only. The nature of the information in all of the articles is intended to provide accurate and authoritative information in regard to the subject matter covered.

The information contained within this site has been sourced and presented with reasonable care. If there are errors, please contact us by completing the form below.

Timeliness: Note that most articles published on this website remain on the website indefinitely. Only those articles that have been published within the most recent months may be considered timely. We do not remove articles regardless of the date of publication, as many, but not all, of our earlier articles may still have important relevance to some of our visitors. Use appropriate caution in acting on the information of any article.

Report inaccurate article content:


Submit this form, and an Enrollment Specialist will contact you to answer any questions.

*All fields required.

Or call 844-351-6656

By submitting this form, I am providing my digital signature agreeing that Northeastern State University (NSU) may email me or contact me regarding educational services by telephone and/or text message utilizing automated technology or a pre-recorded message at the telephone number(s) provided above. I understand this consent is not a condition to attend NSU or to purchase any other goods or services.

Dots graphic

Begin Application Process

for help with any questions you have.

Dots graphic

Request Information

U.S. flag

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Logo of ijerph

Communication Skills, Problem-Solving Ability, Understanding of Patients’ Conditions, and Nurse’s Perception of Professionalism among Clinical Nurses: A Structural Equation Model Analysis

This study was intended to confirm the structural relationship between clinical nurse communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. Due to changes in the healthcare environment, it is becoming difficult to meet the needs of patients, and it is becoming very important to improve the ability to perform professional nursing jobs to meet expectations. In this study method, structural model analysis was applied to identify factors influencing the perception of professionalism in nurses. The subjects of this study were 171 nurses working at general hospitals in city of Se, Ga, and Geu. Data analysis included frequency analysis, identification factor analysis, reliability analysis, measurement model analysis, model fit, and intervention effects. In the results of the study, nurse’s perception of professionalism was influenced by factors of communication skills and understanding of the patient’s condition, but not by their ability to solve problems. Understanding of patient’s condition had a mediating effect on communication skills and nursing awareness. Communication skills and understanding of the patient’s condition greatly influenced the nurse’s perception of professionalism. To improve the professionalism of clinical nurses, nursing managers need to emphasize communication skills and understanding of the patient’s condition. The purpose of this study was to provide a rationale for developing a program to improve job skills by strengthening the awareness of professional positions of clinical nurses to develop nursing quality of community.

1. Introduction

Changes in the environment related to climate and pollution are causing health problems and various diseases such as respiratory and circulatory problems, metabolic disorders, and chronic diseases. Moreover, access to modern healthcare facilities has created greater expectations among patients receiving personalized healthcare and high-quality healthcare. As the difficulty of satisfying the demands of patients increases, enhancing nursing capabilities has become increasingly important [ 1 ]. To improve this, hospitals are making efforts to change the internal and external environments so as to increase the number of nurses, reduce the length of hospital stays, and enable efficient nursing practice. Despite these efforts, the workloads of nurses and the demand for clinical nurses are continuously increasing [ 2 , 3 ]. As a result, nurses are developing negative attitudes and prejudices toward patients, as well as negative perceptions of professionalism. To address this, the cultivation and strengthening of nursing professionals’ capabilities is essential.

Nurses’ perception of professionalism is an important element influencing their ability to perform independent nursing, and a good perception of their profession results in a positive approach to solving patients’ problems [ 4 , 5 ]. In addition, the characteristics and abilities of individual nurses can influence the level of care and enable them to understand patients, solve problems, and provide holistic care, which is the ultimate goal of the nursing process [ 6 , 7 ]. Thus, patients expect nurses to not only have medical knowledge of the disease but to also be able to comprehensively assess the patient’s problems and be independent and creative in nursing [ 8 ]. This attitude can have a major impact on the quality of nursing services and can inspire pride in the nursing occupation and professional achievement. These findings can also be used by nurses to prevent burnout and maintain professionalism [ 9 , 10 ].

To respond to the increasing demands for diverse qualitative and quantitative nursing services and to strengthen the capabilities of nursing professionals, efforts have been made to move nursing education toward scientific and creative education. However, in point-of-care environments, not only are nurses prevented from making independent decisions regarding nursing, but also the diverse personal capabilities necessary for such independent behavior are not sufficiently developed [ 11 ]. Therefore, it is important to enhance clinical nurses’ perceptions of the nursing profession; maintain a balance of nursing capabilities; provide novel, high-quality nursing services; and identify assistive nursing education methods and obstructive environmental factors [ 10 ].

Communication skills involve a person’s ability to accurately understand (through both verbal and non-verbal indications) another person, and sufficiently deliver what the person desires [ 12 , 13 ]. Good communication skills are a primary requirement for providing professional nursing services because they enable an in-depth understanding of patients, solving of complicated problems, and reasonable and logical analysis of situations [ 14 , 15 , 16 ]. When effective communication takes place, nurses’ problem-solving abilities and perceived professionalism strengthen [ 17 , 18 ].

According to Park [ 19 ], nurses have difficulties in interpersonal relationships when social tension and interaction skills are low and communication is poor. In addition, these factors are negatively affected not only in the work of the nurse but also in the perception of the profession. Communication skills are associated with both the formation of relationships with patients and the ability to perform holistic nursing [ 20 ]. In order to improve and develop the overall nursing function of a clinical nurse like this, it is important to complement the relevant integrated nursing abilities [ 21 , 22 ].

Previous studies have investigated the importance of communication skills for nurses, and the relationships between nurses’ problem-solving ability and their understanding of the patients’ conditions. Nonetheless, data that can comprehensively explain the structural relationships between these qualities and how they affect the job perception of nurses remains insufficient.

Therefore, the present study aims to identify the structural model for the relationships between nurses’ communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. Additionally, the study provides basic data necessary for developing programs for improving nursing abilities.

The purpose of this study is to construct a theoretical model that explains the structural relationships among nurses’ communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. In addition, the study aimed to verify this model using empirical data.

2. Materials and Methods

2.1. study design.

To create and analyze the structural model for clinical nurses’ communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism, the theoretical relationships among the variables were developed based on related theories.

In this study, communication skills were set as the exogenous variables, whereas problem-solving ability, understanding of patients’ conditions, and perception of the nursing occupation were set as the endogenous variables. In addition, communication skills were set as the independent variables and nursing job perceptions as the dependent variable. This is because the ability of communication helps to maintain an intimate relationship with the patient and to assess the patient’s condition through each other’s relationship and to solve problems and develop correct understanding. Communication skills, problem-solving ability, and understanding of patients’ conditions were set as the parameters for determining causality. The research model is shown in Figure 1 .

An external file that holds a picture, illustration, etc.
Object name is ijerph-17-04896-g001.jpg

Study model.

2.2. Study Participants

The structural equation model has less than 12 measurement variables. The sample size usually requires 200 to 400 participants [ 23 ]. A total of 250 participants were selected for the study. In line with ethical standards and practices, participants received a full explanation on the purpose of the study. They were briefed that the information collected would be used for research purposes only. Furthermore, they were informed that they could withdraw from the study at any time.

2.3. Data Collection Method

Data collection for this study was performed by two researchers unrelated to the hospital from April 20 to May 1, 2019. A questionnaire was used to collect data from clinical nurses working in five hospitals in Seoul, Gyeonggi, and Gangwon provinces. Of the 250 questionnaires disseminated, we received 225 completed returns. However, 54 were considered inaccurate, inconsistent, or unsatisfactory for coding purposes. Thus, 171 fully completed valid questionnaires comprised the final dataset for analysis.

2.4. Research Instruments

2.4.1. communication skills.

In this study, the communication skill instrument developed by Lee and Jang [ 24 ] was used. Its contents were modified and supplemented to clearly understand the communication skills of nurses. Our questionnaire comprised 20 questions with five questions each concerning “interpretation ability,” “self-reveal,” “leading communication,” and “understanding others’ perspectives.” The answers were rated on a five-point Likert scale ranging from 0 = “strongly disagree” to 4 = “strongly agree.” For this study, the Cronbach’s alpha value was 0.81.

2.4.2. Problem-Solving Ability

The tool developed by Lee [ 25 ] was used to measure the problem-solving ability of clinical nurses. The survey comprised 25 questions, with five questions each concerning “problem recognition,” “information-gathering,” “divergent thinking,” “planning power,” and “evaluation.” Items were scored on a five-point Likert scale ranging from 0 = “strongly disagree” to 4 = “strongly agree.” The internal consistency confidence value Cronbach’s alpha was 0.79.

2.4.3. Understanding Patients’ Condition

To measure nurses’ understanding of patients’ conditions, we developed 10 questions by revising and supplementing items from an existing understanding-measurement tool [ 26 ]. With a total of ten questions, we measured “diagnostic name,” “patient-treatment planning,” and “nursing intervention processes.” Items were scored using a five-point Likert scale ranging from 0 = “strongly disagree” to 4 = “strongly agree.” The internal consistency confidence value Cronbach’s alpha was 0.81.

2.4.4. Nurse’s Perception of Professionalism

Nurse’s perception of professionalism was measured using a tool developed by revising the 25 questions created by Kang et al. [ 1 ]. With a total of ten questions, we measured “vocation” and “autonomy.” Items were scored using a five-point Likert scale. The internal consistency confidence value Cronbach’s alpha was 0.81.

2.5. Data Analysis

To identify the relationships among the set variables, the data were computed statistically using the program included in IBM SPSS 24.0 and AMOS 23.0. (IBM Corp., Armonk, NY, USA). The analysis methods were as follows:

3.1. Demographic Characteristics

The demographic and general characteristics of the study subjects are shown in Table 1 . Overall, 71 respondents were aged 25–29 years (41.5%), representing the most numerous age group. University graduates comprised 113 (66.1%) of the sample, while 50 (29.2%) held graduate degrees, with eight (4.7%) holding master’s degrees. Fifty-three respondents (31.0%) had over seven years of clinical experience, 43 (25.1%) had two to three years of experience, 42 (24.6%) had four to six years of experience, and 33 (19.3%) had less than two years of experience. Additionally, 121 respondents (70.8%) worked at secondary hospitals, while 50 (29.2%) worked at tertiary hospitals; 159 respondents (93.0%) reported that they were general nurses.

Participants’ general characteristics ( N = 171, %).

3.2. Technical Metrics of the Measurement Variables

The multivariate normality of the findings related to the factors of the latent variables was verified through standard deviations, skewness, and kurtosis. The present study meets the criteria for the skewness and kurtosis values mentioned by Hu and Bentler [ 27 ].

All sub-factors of the latent variables secured normality.

In this study, a normal distribution was obtained for each of the four sub-factors of communication skills, five sub-factors of problem-solving ability, three sub-factors for understanding the patient’s condition, and two sub-factors of the nurse’s perception of professionalism as shown in Table 2 .

Technical metrics of the measurement variables ( N = 171).

3.3. Correlations between the Measured Variables

The correlations between the measurement variables were analyzed using Pearson’s product–moment correlation coefficient analysis ( Table 3 ). The correlations among all individual measurement variables were found to show a positive correlation.

Correlations between the observed variables.

3.4. Confirmatory Factor Analysis of the Measurement Model

This study examined how well the measurement variables represented the latent variables in the measurement model. Each set path coefficient was evaluated using non-standardization factors, standardization factors, and standard errors. The path coefficients refer to the factor loadings in CFA. The standardization factors of the individual paths were shown to be at least 0.50 (except for vocation: 0.36), and the critical ratio (CR) was at least 1.96. This indicated that the measurement tool had good convergent validity ( Table 4 ).

Confirmatory factor analysis of the measurement model.

*** p < 0.001; CR: critical ratio.

3.5. Verification of the Structural Model

The structural model for relationships among clinical nurses’ communication skills, problem-solving ability, understanding of patients’ condition, and nurse’s perception of professionalism that would be suitable for predicting the influencing relationships was verified. Since the fitness index of the modified model was shown to be higher than that of the initial model, the final model for this study was set as shown in Figure 2 .

An external file that holds a picture, illustration, etc.
Object name is ijerph-17-04896-g002.jpg

Final model. * χ 2 = 124.074 (df = 61, p <0.001), GFI(Goodness of Fit Index)= 0.90, RMSEA(Root Mean Square Error Approximation)=0.07, NFI(Normed Fit Index)=0.87, IFI(Incremental Fit Index)= 0.93, TLI(Tucker-Lewis Index)= 0.91, CFI(Comparative Fit Index)= 0.92.

3.6. Influencing Relationships between Variables of the Study Model

The standardization factors and CR values of the final model were examined to determine whether there were direct relationships between communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. The results are shown

For the relationship between communication ski in Table 5 .lls and problem-solving ability, the standardization factor was 0.85 and the CR value was 7.37; communication skills showed a statistically significant effect. Consequently. The relationship between communication skills and understanding of patients’ conditions also showed a statistically significant effect. Consequently, Hypothesis 1 was supported.

The relationships between the human effects of the measurement model.

* p < 0.05, *** p < 0.001; CR: critical ratio.

For the relationship between communication skills and nurse’s perception of professionalism, the standardization factor was 0.54, and the CR value was 2.02. Communication skills showed a statistically significant effect. Consequently. For the relationship between problem-solving ability and nurse’s perception of professionalism, the standardization factor was −0.056, and the CR value was −0.39. Problem-solving ability had no statistically significant effect. Consequently.

The relationship between nurses’ understanding of patients’ conditions and nurse’s perception of professionalism had a statistically significant effect. Consequently Figure 2 shows the influencing relationships between the study variables of the final study model, considering non-standardization and standardization factors of the relationships between the study variables.

3.7. Direct and Indirect Effects of the Variables

To grasp the significance of the mediating effect in the final study model, the direct and indirect effects of each variable were examined. To examine the mediating effect of the problem-solving ability and understanding of patients’ conditions variables, the bootstrapping method provided by the AMOS 23.0 program included in IBM was utilized. The results are shown in Table 6 .

Mediating effect analysis.

* p < 0.05, *** p < 0.001

The indirect effect of communication skills on nurse’s perception of professionalism through nurses’ understanding of patients’ conditions was statistically significant. That is, clinical nurses’ communication skills have an indirect positive effect on their nurse’s perception of professionalism, with nurses’ understanding of patients’ conditions acting as a parameter. We also found that the effect of communication skills on nurse’s perception of professionalism was statistically significant. Therefore, communication skills have a partially mediated effect on nurse’s perception of professionalism, with understanding of patients’ conditions acting as a parameter. However, communication skills were found to have no indirect positive effect on nurse’s perception of professionalism when problem-solving ability was set as a parameter.

4. Discussion

In this study, we developed and analyzed a hypothetical model regarding clinical nurses’ communication skills, problem-solving ability, and understanding of patients’ conditions, and how these factors influence their nurse’s perception of professionalism.

4.1. Effect of Communication Skills on Nurses’ Perception of Professionalism

Communication skills were found to have statistically significant effects on their relationship with nurses’ problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. Nurses’ communication skills not only affected their problem-solving ability but also their understanding of patients’ conditions and nurse’s perception of professionalism. Good communication among nurses can reduce uncomfortable situations and improve interactions with patients, which can consequently enhance problem-solving [ 28 ]. Supporting our findings, Ancel [ 17 ] reported that communication skills afford the maintenance of amicable cooperative relationships with patients across diverse medical classes, thereby enhancing the efficiency of nursing-related problem-solving.

Nurses’ communication is also closely related to their understanding of patients’ conditions, particularly regarding the treatment processes. Nurses frequently experience difficulties as a result of poor communication with not only patients and their family members but also other medical personnel. Further, poor delivery of explanations and questions affects nurses’ understanding of patients’ situations and problems, and patients can also feel concern regarding whether nurses accurately understand their problems [ 29 ]. Nurses frequently experience psychological abuse when communicating with patients and develop stress or discomfort [ 30 ]; this can lead to distrustful relationships with and inhibited understanding of patients [ 31 , 32 ]. Vermeir et al. [ 18 ] reported that scientific approaches are required to understand patients in-depth. To accurately understand both oneself and others, the most important method is successful communication. Such findings support the present study’s indication that nurses’ communication is a basic means of solving nursing problems, with both actions being interrelated.

Our finding that nurses’ communication skills are structurally related to their nurse’s perception of professionalism supports the findings of many previous studies. Regarding nurse’s perception of professionalism, Adams et al. [ 33 ] as well as Lee and Kim [ 34 ] explained that a good perception leads to higher-level capabilities, fostering high-level nursing of patients and the development of autonomous vocation. The above studies reported that, since nurses’ communication skills are related to their nurse’s perception of professionalism, communication skills should be considered a predictor of success. Further, McGlynn et al. [ 35 ] recommended positively reinforcing communication skills to improve nurse’s perception of professionalism. This supports the findings of the present study, indicating that communication and nursing professional perception are interrelated.

Thus, communication skills are important for nursing patients. They enable nurses to accurately understand patients’ problems, serve (by forming patient trust) an important function in the process of administering nursing interventions, and positively affect nurses’ perception of their profession. As such, each concept is important. However, nurses working in the clinic are critically aware of their professionalism. In order to reinforce this, communication skills are required, and the emphasis is placed on strengthening the nurses’ ability to solve problems as well as assess and understand patients. As a result, communication skills play an important role in helping nurses understand patients’ problems accurately, build patient trust in nursing interventions, and create structural relationships that have a positive impact on the perception of nursing occupations. Therefore, efforts to improve nurses’ communication skills not only improve their problem-solving abilities and understanding of patients’ conditions but also improve their nurse’s perception of professionalism. To maintain the professionalism of nurses, “competency development programs” would be helpful, thereby emphasizing the need for their application in nursing colleges and clinical practice.

4.2. Relationship between Nurses’ Problem-Solving Ability and Nurse’s Perception of Professionalism

We found clinical nurses’ problem-solving ability to have no positive effect on their perception of professionalism. This contrasts with previous studies, which reported that problem-solving ability is helpful for such perception of professionalism [ 36 ]. We also found that problem-solving ability does not affect nursing professional perception through a mediating effect.

The present findings indicate that the distinctiveness of the fields of nursing should not be overlooked. In nursing organizations that have a culture of discouraging diversity, when negative results are obtained from attempts to solve nursing problems, confusion regarding the identity of nursing professionals means perception of the profession is not reinforced; in many cases, the opposite perception is formed. Furthermore, for those in lower-level positions, nurse’s perception of professionalism is thought to be low because they cannot voice their opinions and have difficulties such as excessive workloads. Although few previous studies have directly examined this, Vermeir et al. [ 18 ] explained that, as the role expectation for nurses increases, factors for job turnover increase as a result of a sense of confusion regarding the nurses’ role and increases in stress. These findings indicate that factors that degrade nurses’ problem-solving ability induce skepticism regarding nursing and possibly career change, thereby supporting the findings of this study.

However, in the present study, positive results with low levels of relevancy in the structural model but high correlations were found. It is expected that, if nurses’ environmental conditions are improved and their nursing capabilities are developed so that they can solve nursing problems with confidence, their nursing professional perception will improve.

4.3. Relationship between Nurses’ Understanding of Patients’ Conditions and Nurse’s Perception of Professionalism

Our findings indicated that the relationship between nurses’ understanding of patients’ conditions and nurse’s perception of professionalism was statistically significant. This supports Nilsson et al. [ 21 ] and Philip et al. [ 29 ], who reported that, in the fields of nursing, when patients accurately understand nurses’ instructions or explanations and health information, they can participate in, independently adjust, and engage in creative decision-making related to self-nursing.

McGlynn et al. [ 35 ] suggested that understanding patient problems is an important element in resolving negative situations; meanwhile, Heo and Lim [ 37 ] indicated that clinical nurses provide high-quality nursing services and develop self-efficacy when they apply professional knowledge and a desire to understand patients’ problems. These study findings accord with our own findings.

The aforementioned findings suggest that the development and application of programs that can enhance nurses’ understanding of patients’ conditions should be emphasized, and that studies of various patient types, the characteristics of patients by age group and hospital areas, as well as the introduction of simulation education programs to improve nurses’ understanding of patients’ conditions should be continuously implemented.

5. Conclusions

This study aimed to verify the structural relationships between clinical nurses’ communication skills and their problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism. We also aimed to identify, through a structural model, the mediating effects of nurses’ problem-solving ability and understanding of patients’ conditions in the relationship between communication skills and nurse’s perception of professionalism.

The findings of this study are as follows (all significance levels = 0.05). In the relationship between communication skills and problem-solving ability, the value of the standardization factor was 0.85 and the CR value was 7.37, indicating that communication skills had a statistically significant effect. In the relationship between nurses’ communication skills and understanding of patients’ conditions, the value of the standardization factor was 0.61 and the CR value was 6.35, indicating that communication skills had a statistically significant effect. In the relationship between communication skills and nurse’s perception of professionalism, the value of the standardization factor was 0.54 and the CR value was 2.02, indicating that communication skills had a statistically significant effect. However, in the relationship between problem-solving ability and nurse’s perception of professionalism, the value of the standardization factor was −0.05 and the CR value was −0.39, indicating that problem-solving ability has no statistically significant effect. Finally, in the relationship between nurses’ understanding of patients’ conditions and nurse’s perception of professionalism, the value of the standardization factor was 0.56, and the CR value was 2.14, indicating that nurses’ understanding of patients’ conditions has a statistically significant effect.

There are some limitations to this study. First, as we only examined nurses at secondary and tertiary university hospitals, our findings may not be generalizable to all clinical nurses. Replication studies examining a range of levels of medical institutions and associated workers are necessary. Second, the structural relationship between problem-solving ability and the nurse’s perception of professionalism turned out to be insignificant or mediated. Subsequent studies on the various approaches to revisit this structural relationship should be performed. Third, theories should be systematically developed to establish the values of the nursing profession, and additional studies are necessary to explore other variables.


We would like to thank the staff nurses who participated in the survey and took the time to complete the initial assessment.

Author Contributions

Conceptualization, A.Y.K. and I.O.S.; methodology, A.Y.K.; software, I.O.S.; validation, A.Y.K. and I.O.S.; formal analysis, A.Y.K. and I.O.S.; investigation, A.Y.K.; resources, A.Y.K.; data curation, A.Y.K.; writing—original draft preparation, A.Y.K.; writing—review and editing, A.Y.K. and I.O.S.; visualization, A.Y.K. and I.O.S.; supervision, I.O.S.; project administration, I.O.S. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

People also looked at

Original research article, sustainability of nursing leadership and its contributing factors in a developing economy: a study in mongolia.

problem solving nursing leadership

The sustainability of nursing leadership is a very important problem. Every country continually strives to find the best ways to advance in nurse management and patient care services. Nursing leadership is most desirable in the delivery of health care services. Since there is limited information about leadership skills in Mongolia, to solve the problem of the sustainability of nursing leadership, we carried out this study to explore factors contributing to the sustainability of nursing leadership and their correlation relatively to nurse managers in healthcare institutions. A sample of 205 nurse managers from all forms of health facilities participated in this study. The data were analyzed by descriptive, correlation, and multiple linear regression models using SPSS 19 version. The linear combination of the five independent variables was significantly related to the dependent variable (nurse leadership). Both the behavior and problem-solving are significant regressors of the dependent variable. The correlation analysis significance of the independent study variables, two were found to have a significant effect on nursing leadership: behavior and performance of nurses significantly and positively effect nursing leadership. The transformational role and nurse leadership produced a significantly positive Correlation coefficients give a direction of causation in the relationships of variables, and the multiple linear regression analysis says that two of the variables, namely, behavior and problem-solving, positively contribute to nursing leadership, two of the variables namely, work environment and performance nurse manager do not support; however, variable transformational ability majorly contributes to the sustainability of nursing leadership.


The sustainability of nursing leadership is a very important problem. Healthcare is one of the challenging industries that require complex demands, and needs successful recruitment strategies; however, it is quite difficult to select competent professionals and keep them for a longer period of time. As a growing segment of the population ages, each country strives to find the best way to improve its nursing management and patient care system. Nurses play an important role as doctors in the delivery of health care services. Due to the increased demand for nurse managers, the form of leadership is most desirable in the daily working environment of nurses ( 1 – 4 ).

Nurse managers engage in a range of leadership activities in their daily routine that some will naturally adopt an effective leadership style and provide higher leadership roles, while others may find the concept of leadership is difficult to understand or see themselves not so much competent. Nurse leaders should have rational thinking and exceptional communication skills that are measured by the positive influential ability to reach the goals of health care. The key role of nurse managers is to motivate their subordinates to be autonomous in making patient care decisions and perform safe patient care according to the standards of nursing practice ( 5 – 7 ).

Leadership is important in high-quality patient care and facilitating positive staff development in healthcare settings. Effective leadership significantly influences reducing turnover of nurses and increasing job satisfaction in the workplaces ( 8 , 9 ). According to literature, leaders should be able to work under pressure and take immediate actions to solve problems, and, at the same time, be both taught and learned in the work environment. Nevertheless, leaders must show emotional intelligence to manage their own and others' feelings. In addition, leaders must have a transformational role to influence their own and others' performances that impact problem-solving in the workplace ( 9 , 10 ).

Nowadays, the leadership role of nurses depends on rapid technological changes, communication style, information transparency, needs of patients, service quality, and compliance with regulations and standards ( 8 ). Besides, the nurse manager is a coach, while nurses provide high-quality patient service, stabilize workload and stress, and increase efficiency in the workplaces. Typically, the leadership of nurse managers is developed through specific educational activities by modeling and practicing competencies ( 11 ). Nevertheless, cultural differences influence nursing leadership, for instance, in Arabic countries, nurse managers have an integrative leadership role; in spite of it, in western countries, nurse managers prefer to be decentralized ( 12 , 13 ).

With the notable shift in the healthcare needs of global populations, healthcare institutions across the world face enormous challenges to be more responsive and efficient, a responsibility that cannot be met without ensuring good quality of nursing care. Yet, due to inconsistent economic development, the quality of nursing varies significantly from country to country. In developing countries, such as Mongolia, nurses work, often under difficult circumstances, in health services that are grossly underfunded and are a vailable only to those who can pay ( 14 ).

Over the last decades, the health care industry in Mongolia has faced a series of problems, such as low quality in care provision, human resources scarcity, inadequate training, and insufficient ongoing education for nurses and nursing leadership, as well as poor working environments. In spite of that, nurses work hard to facilitate their resources to their job without considering the environment.

In brief, Mongolia is a landlocked developing country, which is between China and Russia, with a population of 3 million, the majority of which live in the capital city. As of 2020, the life expectancy in Mongolia was 69.9 years. By 2012, there were 9,916 registered nurses (see Table 1 ), while this number increased to 10,948 in 2016 ( 4 , 15 , 16 ).

Table 1 . Number of hospital and nurses.

Studies discuss that insufficiency in autocratic nursing leadership is common within hospital settings of Mongolia, which is the main problem of this study ( 8 ). According to the literature, the common factors that have a positive effect on nursing leadership are work environment, performance, behavior, problem-solving, and transformational role ( 18 ), which are discussed in section Literature Review and Research Hypotheses more in detail. Thus, the purpose of this study is to explore factors that affect nursing leadership in healthcare institutions of Mongolia. We hope that this study will also serve as a catalyst for further exploration of influencing factors on leadership in developing countries. This study provides instruments in helping hospital administrators to meet the needs of long–term employment of nurses in their organizations. A greater understanding of nurse leadership changes people's minds and functions and increases healthcare quality and patient care services in hospitals of Mongolia. This study has a critical implication on Government policies and regulations on how to develop nurse managers in healthcare settings around the country.

The remainder of the paper is organized as follows. Section Literature Review and Research Hypotheses reviews relevant literature and describes the hypotheses to test. Section Methods presents the methodology. Empirical results are reported in section Data Analysis, while section Conclusions and Discussions presents the conclusions of the paper.

Literature Review and Research Hypotheses

The theoretical foundation of this study is based on leadership theory, management theory, and psychological theory of nurse managers that influence the activities and competence of an individual or a group in efforts to have goals of achievement in a given situation. Leadership theory says that some people are born to be leaders, while, according to management theory, leadership is a position and a skill that can be earned and developed through years of experience ( 11 , 19 ). According to the psychological theory, naturally, women have lower aggressiveness that restrains women from leadership positions. Nevertheless, gender plays an important role in the nursing profession and remained predominantly female ( 20 , 21 ).

There are a number of definitions and typologies for the leadership role of nurse managers. The majority of studies used the theoretical framework of Hersey and Blanchard's Situational Leadership Model, Kouzes and Posner's Leadership Challenge, Burns' Transformational Leadership, Bass and Avolio's Transformational and Transactional Leadership, McLelland's Theory of Leadership Motivation ( 22 ). They found 20 factors that affect the leadership role and categorized the factors into four groups: [1] behaviors and practices; [2] traits and characteristics; [3] context and practice settings; and [4] educational activities.

Other scholars described nurse roles functions as an independent role function, a dependent role function, and an interdependent role function ( 23 ), which are similar to the classification of managerial theory ( 18 ) as classified into three major roles: [1] interpersonal, derived from authority and status including the role's figurehead, leader, liaison; [2] informational, derived from interpersonal roles, including the role's monitor, disseminator, and spokesman, and [3] decisional, derived from a manager's information, including the roles of entrepreneurs, disturbance handlers, resource allocators, and negotiators.

As stated in the research of Ramey ( 5 ), the leadership role prevents turnover and promotes retention, which is economically important for hospitals and healthcare institutions. Koy et al. ( 9 ) found that nursing leadership plays an important role in nursing managers' job satisfaction, organizational commitment, and workplace empowerment.

Thus, this study makes a general proposition (see Figure 1 ) that factors, such as work environment, performance, behavior, problem-solving, and transformational role, affect positively nursing leadership.

Figure 1 . Theoretical framework.

Work Environment

A nurse's role in the workplace encompasses illness prevention and care, health promotion and disabilities and palliative care, whereas a leader's role of nurses in the workplaces is to create a conducive work environment ( 23 – 25 ). Nurses are required to work overtime, and extra shifts are creating a stressful work environment. Therefore, nurse managers aim at maximizing nursing productivity and minimizing the direct and indirect costs of overtime work. Nursing has an important impact on hospital costs and the rational use of resources and reduced waste that reduce delivery of care cost and enable larger investment in quality ( 3 , 11 , 26 ).

Rajbhandary and Basu ( 3 ) identified that improving the work environment has to be identified as one retention strategy, so it is important to identify mechanisms to retain nurses and increase nurse satisfaction while improving the work environment and working conditions. In the healthcare system, a healthy work environment should be created for the appropriate nursing staff level. Nurse managers experience severe psychological stress and a heavy burden at work, which could have conflict in the work environment. A stressful work environment would likely constitute less autonomy, less control, and a lack of respect. Moreover, they create a safe environment for effective management of the conflict to stimulate personal growth and ensure quality patient care ( 9 , 12 , 20 , 24 ).

Many researchers used the Revised Nursing Work Index (NWI –R) and Environment Scale of the Nursing Work index (PES-NWI) to measure factors in the work environment to support professional nursing practice, and explored that leader's role is a critical factor in the work environment ( 27 ). Clinical leaders foster a supportive work environment to empower their subordinate nurses in management positions ( 9 ). A positive leadership role encourages nurses in managerial positions to involve in a common organizational commitment that contributes to an optimal work environment ( 9 , 28 ).

Casida ( 6 ) found that the leadership role of nurse managers is directly influenced by the nursing unit and organizational culture that is responsive to the external and internal perspectives forward to the hospital goals and vision. A positive work environment does not naturally occur, instead created and fostered by strong nurse leaders their visibility, accessibility, consultation, recognition, and support ( 27 ). Thus, the following hypothesis is set to test whether the work environment is positively related to nursing leadership:

Hypothesis 1: Work environment is positively related to nursing leadership.


The performance of a nurse in a healthcare institution is an interaction between people to work together and help the patients, thereby reducing the power imbalance between the patient and the physician and creating dependency on the part of the patients. Nursing performance is critical to the management of a nursing ward and closely tied to role enhancement of nurse managers and job satisfaction ( 11 , 26 , 29 ).

Health care organizations, including nurse care departments face formidable challenges in improving nurse performance, which is the fundamental aspect to successfully excel in many organizational elements and effectively enhance health care quality to patients. Nurse managers with high performance successfully achieve their responsibility in an organization and have a positive influence on nursing leadership; however, nurse managers with weak performance spent considerable energy, articulating the importance of nursing to the organization ( 9 , 21 , 30 ).

Hypothesis 2: Performance is positively related to nursing leadership.

Koy et al. ( 9 ) state that demand for care is skyrocketing, and supply for a caregiver is plummeting that behavioral component is essential for nurse managers. Nursing intervention is defined as assisting a patient, significant others, and/or family to improve relationships by clarifying and supplementing specific role behaviors. Some researchers argue that a behavior element has a positive effect on the nurse manager's role based on the leader-member exchange theory. The behavior of nurse managers is most important in staff nurse satisfaction, engaging nurses in the work environment ( 27 ).

According to Nilsson et al. ( 25 ), role modeling of leadership behaviors by managers, clinical nurse specialists, and other colleagues is developed through a nurse leadership program. Theories of leadership also emphasize positive behaviors are the essential part for leaders. The development of leadership expertise has been described as a process of developing competencies and behaviors over time through education, preceptorship, and mentoring. Supportive interpersonal behavior at work is an important dimension of a nurse manager ( 11 ) that managerial support is directly impacted by the attitude and behaviors of the nurse leaders.

Several studies ( 29 ) used the Collaborative Behavior Scale created by Stichler ( 31 ) to determine the extent of collaboration behaviors that generally exist between nurses and nurse managers. Results of their study show that positive behavior influences positively the leadership role and favorable work environment. They conclude that bad behavior increases workload, turnover, lack of responsibility. Furthermore, the authors suggest that hospital management should stimulate the autonomy of the nurse managers by creating an environment in which career opportunities are clearly delineated in terms of behavior.

In reality, nurses exhibit diverse behaviors, and most of the nurses do not engage in effective conflict resolution, sharing ideas, understanding each other, and communication about what needs to be done for the patient. Therefore, we developed the third hypothesis to examine whether the behavior is positively related to nursing leadership:

Hypothesis 3: Behavior is positively related to nursing leadership.


Problem-solving ability is one of the most important attributes for nurse managers to promote team integration to achieve maximum efficiency. Furukawa and Cunha ( 8 ) argue that, in nursing, problem-solving within teamwork emerged in the 1950s in the USA through experience and a solution to the issue of better use of personnel, as leaders develop and learn new skills and they demonstrate and use these skills in practice while setting teamwork as well as teaching others ( 9 , 22 , 24 ).

According to Aiken et al. ( 7 ), nursing leadership and problem-solving between groups increased significantly following an intervention and communication. Nurses' daily responsibilities are demonstrated by a critical path, a clinical path, or a care path that is an example of how problem-solving is weaved. To improve clinical problem-solving performance then, it would seem fruitful that nurses should be encouraged to develop a strong nursing leadership and well-structured knowledge base in the context of their discipline.

Hospitals do not provide education regarding problem-solving; thus, nurse managers shall have their own ability to solve a problem. Moreover, the nursing department or unit may develop its own module for nurses. Thus, this study postulates the following proposition to test whether problem-solving has a positive effect on nursing leadership:

Hypothesis 4: Problem-solving ability is positively related to nursing leadership.

Transformational Role

One of the main roles of a nurse manager is to motivate followers and value specified and idealized goals, which are determined by the transformational role. A number of studies used the Leadership Practice Inventory approach to measure nurse managers in perception of leadership abilities to deemphasize that extraordinary nursing leadership composes of transformational roles. Using the method, Krugman and Smith ( 32 ) compared outcomes between two units: one with transformational leadership and the other one with conventional management. Their finding shows that nurses with transformational roles have a high rate to be nurse leaders, respected within an institution by departments and physicians.

Registered Nurses' Association ( 33 ) reports that support from colleagues with transformational qualities is important for nurse leaders. A transformational leadership ability of individuals broadens and motivates both parties to achieve greater levels of achievement, thereby transforming the work environment; moreover, it could be a great way to generate an optimum decision.

Highly and moderately relevant transformational roles are common among experienced nurses, while low and moderately relevant interpretations were more evident among young or non -experienced nurses ( 25 ). Researchers found that the transformational role of nurse managers is positively related to empowerment, and transformational leaders have a clear vision for the future and values in an ongoing dialogue with nurses. Nurse managers empower subordinates by motivating them to share in the vision and make it a reality; thus, they should have a transformational role to some extent. Consequently, the following hypothesis is set to examine whether the transformational role has a positive impact on nursing leadership:

Hypothesis 5: The transformational role is positively related to nursing leadership.

Nursing Leadership

It is evident that leadership in nursing is of supreme importance at this time. The managerial career and nursing leadership are frequently seen as an award, an acknowledgment of a nurse's contribution to an organization and patient care services ( 8 ). Casida ( 6 ) discusses that a competitive leadership role is crucial for patient satisfaction and must be the survival of any healthcare facility that remains a priority of nurse managers. Nurse managers find themselves facing a challenging global nursing shortage—that the need for health care grows rapidly worldwide.

There are a variety of standards applicable to the practice of nursing leadership. The standards are based on the values of the profession, work environment, nursing actions, and interventions that a nurse implements to achieve desired outcomes in a particular hospital setting. Despite it, the hospital size is considered to be a fundamental feature with important implications for nursing leadership in hospital settings. Furthermore, nursing leadership is higher in bigger hospitals than in small ones ( 10 ).

Generally, it is acknowledged that one learns to be a leader by serving as a leader. One is a leader when he or she exercises leadership. Nurses progress throughout their careers as they face new challenges and conflicts in the workplaces. The establishment of criteria for the selection of nurse managers depends not only on years of experience but also on personality and management skills ( 4 , 9 , 12 ).

Nurse managers with positive leadership effects have their own self-interest for a higher purpose and stimulate followers, while those with negative leadership effects avoid leadership responsibilities and take action when issues become serious. When positive nursing leadership exists within nurse managers, patient satisfaction tends to be high, while turnover of nurse staff becomes low. Nevertheless, leadership policy shall be formulated by the human resources department, involving all management levels.

To solve the problem of the sustainability of nursing leadership, the purpose of this study was to examine the relationship between nursing leadership and contributing factors to it, such as work environment, performance, behavior, problem-solving, and transformational role. We used a multifactor questionnaire survey method to collect data. This study has a descriptive and predictive design. Thus, the empirical data examination procedure consists of descriptive statistics, correlation, and multiple linear regression analysis.

Sample and Design

During the study period, a total of 9,916 nurses worked in 2,881 health care settings of Mongolia, of whom 406 were registered nurse managers having worked as nurse managers for at least 1 year ( 17 ). On average, a nurse manager supervises 24 nurses. To design the sample, the first step consisted of listing all level health care institutions in Mongolia. These comprised 492 primary-level health care institutions, 28 secondary-level health care institutions, 21 tertiary-level health care institutions, and 2,340 other health care institutions, representing 128, 83, 79, and 116 nurse managers, respectively. Since the target population, 406, is not large, we purposively distributed the coded questionnaire to all nurse managers.

Questionnaires were distributed to the nurse managers of each participating hospital. The response rate achieved in this study was relatively high. All analyses were conducted at the 0.05 significance level. The participants were informed that the findings of this study may not benefit them directly, but, by being part of this study, they contribute to a better understanding of nurse leadership, patient care, and hospital structure of the Mongolian healthcare system. A copy of the summary of findings from the study was submitted to the Ministry of Health of Mongolia for a further policy implication. The coded questionnaire was taken from 205 nurse managers as over 50.4% of the total nurse managers in Mongolia in various hospitals of Ulaanbaatar and provinces. SPSS version 19 was used in data analysis.

The following procedures were employed to study the relationship between the dependent variable, nursing leadership, and the independent variables, including work environment, performance, behavior, problem-solving, and the transformational role. In each hospital, the head of nursing distributed the questionnaires to their nurse managers, and, when completed, they were collected from the nursing unit. The questionnaires were given to their home to respond with their convenience and returned a week later through the head or director nurses.

The response rate achieved in this study was comparatively good in comparison with other studies on nurse managers and leaders. Data collection that started in June 2013 was completed by September 2013. Basic demographic information about gender, age, education level, position level, and years of experience was added to the survey tool for all the participants to investigate how the demographics affect nursing leadership.

Study permission was obtained from seven hospital directors. All the participants had signed on the consent form prior to data collection and their rights to privacy and confidentiality.

The following are the seven parts of the survey questionnaire (see Appendix A ).

1. Demographics include gender, age, education, position, and years of experience.

2. Fundamental features include organizational structure, basic knowledge of “leadership” and policy of particular hospital settings.

3. Work environment represents how nurse manager environment allows making autonomous nursing care decisions to suit patient needs that impact nursing leadership.

4. Performance represents how a nurse manager assesses nurse performance, how to decide to provide training sessions to teach new nursing technologies, develop new medical techniques, improve performance, anticipate and prevent misunderstanding/conflicts, redefine goals, consolidate teamwork for effective nurse leadership.

5. Behavior—how nurse managers enact the behaviors that convey support to staff and impact nursing leadership.

6. Problem-solving—how nurse managers effectively solve problems to be able to decrease the cost of health care and to increase the quality of patient care, and

7. Transformational role—how nurse managers adapt innovativeness of their approaches to the work and impact nursing leadership.

The five factors significantly contribute to nursing leadership that tested for the build, convergent, and distinguishable validity. The questionnaire consisted of a series of items with a five-point Likert scale (5 = strongly agree,…, 1 = strongly disagree) that reflects five factors of nursing leadership.

Fundamental features include the level of hospital size as to whether primary, secondary, tertiary, or other types of healthcare institutions. A few questions were asked from the participants to know nurses' knowledge about leadership and how hospital policy influences career development and nurse leadership. These fundamental questions are to identify an area of focus of nurses, hospitals, and to determine an area that needs attention to strengthen the effectiveness of leadership in the future.

Operational Definitions

• Behavior of leadership is the ability to think critically, ability to solve problems, have respect for people, communicate skillfully, have the tendency to set goals, share vision, and have development of self and others ( 9 ).

• A healthcare institution is any hospital, convalescent hospital, health maintenance organization, health clinic, nursing home, extended care facility, or other institution devoted to the care of a sick, infirm, or aged person ( 18 ).

• Leadership is the position or function that organizes and guides a group of people to achieve a common goal and may or may not have any formal authority. The leadership role is building tolerance for ambiguity, setting performance standards for confidence, and holding subordinates accountable to those standards ( 18 ).

• Nurse is the protection, promotion, and optimization of health and abilities; prevention of illness and injury alleviation of suffering through the diagnosis and treatment of human responses and advocacy in health care for individuals, families, communities, and populations ( 33 ).

• A nurse manager is the nurse with management responsibilities of a nursing unit and requires strong leadership ability, clinical nursing knowledge, and decision–making within organizations employing nurses. The nurse manager does planning, organizing, staffing, directing, and controlling. The nurse manager is a middle manager who has 24-h responsibility for one or more hospitals or clinic units, regardless of the title assigned to that position. This position includes direct supervision of charge and staff nurses on all shifts and accountability for those positions [( 4 )].

• Performance is the accomplishment of a given task measured against preset known standards of accuracy, completeness, cost, and speed, which is the process of creating a work environment to enable perform best of the nurses' abilities [( 25 )].

• A problem solver is able to do direct and indirect interventions, delegation, purposeful inaction, consultation, and collaboration with others ( 4 ).

• A transformational role is “Four I's” as an idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration ( 14 ).

• Work environment includes the surroundings, and conditions of influences that affected performance, role enhancement, and professional relationship in the short and long terms ( 21 ).

Data Analysis

This section presents the demographics, analysis on fundamental features, correlation analysis, and multiple linear regression analysis.


This part is about participant demographics. Demographics include gender, age, education, work experience, and position with effects on both nurse retention and nursing leadership. First, descriptive statistics are used to describe the demographics of nurse managers.

Table 2 shows that 96% of the participants were female and only 9 male nurse managers. The data mean that nursing positions are dominated by the female group, which influences the leadership position as stated gender plays an important role in the nursing profession and remained predominantly female.

Table 2 . Gender of participants.

Table 3 shows that 42% of the sample was aged 41–50 years old, 37.6% of them were 31–40 years old, 11.3% of the participants were 20–30 years old, and 9.3% of them were aged 51–60 years old, respectively.

Table 3 . Age of the participants.

These data show that the majority of nurse managers aged between 31 and 50, which were able to gain work experience, the transition of knowledge, and clinical “know-how” from one generation of nurses to another, are imperative for nurse managers. Nurses with <1 year in the profession are more likely to quit their jobs. Nursing leadership makes older nurses stay in the workforce as long as they want by making a simple adjustment to the work environment.

Table 4 shows that 59.5% of the respondents have an associate diploma education, 40% of participants have a bachelor's degree, and only one nurse has a master's degree. All the nurses were graduated in Mongolia.

Table 4 . Education of participants.

Nursing education and the profession have a paralleled opportunity in today's health care system. Unfortunately, the current nursing education is not adequate to meet the needs of the future. Education must develop new partnerships with the community and healthcare institutions. More emphasis and resources must be directed to preparing bachelor's- and master's-level nurses that effective nursing leadership is grounded in the education of nurses in order to achieve successful outcomes.

Table 5 shows that 57% of the nurses are head nurses, 26% of them are registered nurses, about 10% of them are methodologist nurses, and around 6% of the participants are chief nurses.

Table 5 . Position of participants.

Leadership myth is associated with the position. Moreover, the values of leadership involve occupying the top position in a hierarchy. A nurse manager is general terminology and divided into several positions, such as a director nurse of the nurse department; head nurses are senior nurses in a nurse unit or nurse department, and methodologist nurses are trainers of nurse staffs, who are supervised by the director of hospital settings, respectively. Nurses are former nurse managers; however, they currently hold the position of a nurse.

Table 6 shows that approximately 43% of the participants have 21–30 years of work experience, around 33% of them have 11–20 years of work experience, 16.6% of them have 0–10 years of work experience, and 7.8% of them have 31–40 years of work experiences. Data support the relationship between characteristics of the nurse manager workforce and the nurse leadership, which means nurses with longer work experiences are significantly more satisfied than their less-experienced colleagues with most of the facets of their work ( 34 ).

Table 6 . Years of experience of the participants.

Our data show that between 11 and 30 years of work experience affects nurse managers' positions. Nurses with <10 years of work experience or more than 30 years of work experience do not hold a nurse manager position.

Analysis of Fundamental Features

The study took place at public and private hospitals in the capital city, Ulaanbaatar, and other provinces of Mongolia. The nursing population was diverse, including large hospitals and small healthcare settings. Fifty-one nurse managers are from primary-level hospitals as 24.9% of total participants, 72 nurse managers are from secondary-level hospitals as 35.1% of the total participants and 40 nurse managers are from tertiary hospitals as 19.5% of the total participants, and 42 nurse managers are from other healthcare institutions as 20.5% of the total participants.

The primary hospitals require having 4–20 nurse staff, and one head nurse supervises other nurses, but it does not have a director nurse or a methodologist nurse. Every secondary and tertiary hospital must have a nurse department consisting of one nurse director, two to five methodologist nurses, and around 20 heads in order to manage 250 nurse staff. Other hospital settings, such as healthcare departments in 21 provinces and Ulaanbaatar city, must have at least one nurse manager, either in the position of a director nurse or head nurse.

In addition, we investigated whether nurse managers have knowledge about “leadership”; hence, first questions were “Do you know the word “Leadership?” About 157 nurse managers or 76.58% of the total participants know about it; unfortunately, 48 nurse managers or 23.41% of the total participants do not know about the term “leadership.”

Also, some policy-related questions were asked and analyzed as follows. First, “Do hospital policies and procedures have to support the leadership of nurse managers?” About 118 nurse managers or 57.5% of the total participants answered “Yes,” 38 or 18.5% answered “No,” and 49 nurse managers or 23.9% gave an answer of “Do not know.” Second, “Does a nurse manager influence mission and decision-making of general administration issues of the organization?” About 161 nurse managers or 78% of the total participants answered “Yes,” 33 or 16% answered “No,” and 11 nurse managers or 5.3% gave an answer of “Do not know.” Third, “What level of leadership responsibility does nurse manager need?” About 161 nurse managers or 78.5% said “High,” 33 nurse managers or 16% said “Medium,” and 11 nurse managers or 5.5% of the total participants said “Low.”

These fundamental questions are considered to know nurse managers' complaints and suggestions about leadership in the nursing department and hospital settings. Managers who talk to their staff on a regular basis are more informed and have less difficulty when situations occur and increase job satisfaction of nurses, furthermore effects to nursing leadership. Nurses should participate in the policy arena and the decision-making procedure and be engaged in health care reform-related implementation efforts. Increasing the involvement of nurses in high-level leadership contributes to a more stable workforce and, in turn, positively impacts patient quality and safety and transparency and accountability of hospital settings structure.

Correlation Analysis

The relationship between the dependent variable as nursing leadership and five independent variables as work environment, performance, behavior, problem-solving, and transformational role was examined using correlation analysis. Significance was tested at the alpha = 0.05 level. Correlation studies are appropriate when there is a need to clarify the relationship, and little or no previous research has been undertaken. Possible relationships were examined using Pearson correlation coefficients shown in Table 7 .

Table 7 . Pearson correlation.

In terms of the independent study variables, two were found to have a significant effect on nursing leadership: behavior and performance of nurses significantly ( p < 0.05) to nursing leadership positively. The transformational role moderately ( p < 0.05) intercorrelated with nursing leadership. However, the work environment and performance were found not to be strongly related to nursing leadership when entered with the other independent variables.

Table 7 shows the results of a Pearson correlation coefficients; nurse leadership ( n = 205), informed that there was a strong correlation r (205) = 0.90, p = 0.000 between the behavior and nurse leadership and r = 0.36, p = 0.000 between problem-solving and nurse leadership. Also, the transformational role and nurse leadership produced a positive correlation r = 0.159, p = 0.023. However, there is no relationship between performance and nurse leadership r = 0.092, p = 0.189, and between work environment and nurse leadership r = 0.047, p = 0.505.

The results suggested that successful nurse leadership is based on behavior and problem-solving. This opens the floodgates to nurse leadership development, as opposed to simple psychometric assessment that sorts those with leadership potential from those who will never have the chance. Leaders must be taught how to adapt and change constantly to keep up. Also, problem-solving is the most crucial and common thinking process used in nursing that requires various mind actions. This enables them to more accurately represent the nature of the clinical problem and to deal with the problem less in sequential terms in order to override clinical concepts. Thus, the findings support Hypotheses 3 and 4.

The majority of nurse managers are female, and the female leaders scored higher than the male leaders on all transformational roles, because it provides them with a means of overcoming the dilemma of the role and ability to meet the requirement of their leadership role. Therefore, this study supports Hypothesis 5 that the transformational role positively affects nursing leadership.

The work environment and performance are outcome variables that are determined to be mediated by the workload of nurses ( 3 ); however, the findings of this study do not support Hypotheses 1 and 2 that variables significantly low contributes to nursing leadership at the hospital level. These results show that, in Mongolia, nursing leadership is strongly correlated with behavior, problem-solving, and transformational roles, and nurses' performances and work environment must be improved to create a professional practice environment for nurse managers.

Multiple Linear Regression Analysis

Inferential statistics, including R-square, regression, and multiple linear regression analysis, are used to test the validity of the set hypotheses. Multiple linear regression analysis determines whether nurse leadership perceives work environment, performance, behavior, problem-solving, and transformational role. The linear combination of the five independent variables was significantly related to the dependent variable (nurse leadership), R squared = 0.83, adjusted R squared = 0.83, or 83% of the total variance in the dependent variable.

Table 8 contains the ANOVA and shows the factors that contribute to nursing leadership. The analysis shows that there is a difference with an F score of 5, 199 = 204.81 and significance (0.000) well-beyond the alpha < 0.05 standard.

Table 8 . Multiple linear regressions for a single set of predictors: a model summary.

The multiple linear regression analyses showed that behavior and problem-solving positively contribute to nursing leadership. But work environment, performance, and transformational roles do not contribute to nursing leadership. The level of statistical significance was set a priori at = 0.05. Table 9 shows that the model analysis included the five independent variables of the work environment, performance, behavior, problem-solving and transformational ability. The behavior ( t = 29.058, p < 0.05) and problem-solving ( t = 4.693, p < 0.05) are emerged as a significant coefficient of the dependent variable. No other variables in the model were significant.

Table 9 . Multiple linear regressions for a single set of predictors: coefficients.

There is, therefore, a need to develop a work environment in a hospital setting and enhance performance and encourage transformational roles in order to strengthen the effectiveness of nursing leadership.

The results from the regression equation for the standardized variables were as follows: Predicted work environment score = 0.006 + (−0.104) (performance) + 1.017 (behavior) + 0.155 (problem solvency) + 0.025 (transformational ability) ( Table 9 ). The findings provide support for the hypotheses (H3 and H4). These findings answer Research Questions 1 and 2 positively. The 0.000 significance level is less than the level of significance for the test of (0.05). However, the findings do not support Hypotheses 1 and 2, and weak support Hypothesis 5. Behavior was determined to be the strongest predictor of the five variables, and work environment was the weakest predictor of nursing leadership.

Nurse managers must have positive behavior and capable problem-solvers because their profession requires a high level of cognitive reasoning and discretionary decision-making that supports Hypotheses 3 and 4 as behavior and problem-solving contribute to nursing leadership. The transformational role is more focused on processes that motivate followers to perform to their full potential by influencing change and providing a sense of direction for nurse managers. Therefore, this study found that the transformational role slightly contributes to the nursing leadership as finding supports Hypothesis 5.

Minimizing nurse staff workload and enhancing nurse staff job satisfaction should be consistent with retaining nurse leaders in the profession. Unfortunately, this study does not support Hypothesis 1 that the work environment does not contribute to nursing leadership. The nurse manager must assess and improve nurse staff's performance, decide to provide training sessions to teach nursing technologies, and consolidate teamwork. But this study does not support Hypothesis 2 that performance does not contribute to nursing leadership.

Conclusions and Discussions

To solve the problem of the sustainability of nursing leadership, the purpose of this study is to examine the factors that contribute to nurse leadership in hospital settings in Mongolia. This section discusses the findings in relation to the theoretical framework, stated limitations, and presented suggestions and concluding remarks on the further implication of research.

This study is the first research in the literature to assess nursing leadership in Mongolia. Correlation coefficients give the direction of causation in the relationships of variables. According to the results of multiple linear regression analysis, two of the variables, namely, behavior and problem-solving, have strong positive influence on nursing leadership. Nonetheless, work environment and the transformational role do not have significant impact on nursing leadership. Finally, performance has a weak significant influence on nursing leadership.

This study is essential to develop nursing practice, increase the reputation of nurses, and motivate nurses to work in hospital settings for independent decision-making of patient care. Leadership is an observable, learnable set of practices with the desire and persistence to lead—to make difference—that can substantially improve nurse abilities.

The realities of a global society, expanding technologies, and an increasingly diverse population require nurses to master complex information, to coordinate a variety of care experiences, to use technology for health care delivery and evaluation of nursing outcomes, and to assist clients with managing an increasingly complex system of care, which wholly requires to have nursing leadership.

Nursing leadership promotes harmonious interaction between persons and their environment, strengthens the wholeness of an individual, and redirects human and environmental patterns or organization to achieve maximum health. The nursing leadership congress is designed to help nurses become catalysts, and it provides an opportunity to share practical experiences in solving many problems in the health care industry. It focuses mainly on practical experience rather than a theoretical approach. By postulating new factors and relationships and confirming the relevance of leadership factors and their relationships, the study has opened up new horizons for other researchers to investigate more deeply and precisely.

Whereas correlation coefficients give the direction of causation in the relationships of variables, the multiple linear regression analysis attempts to explore the relationship between independent and dependent variables. Hypothesis tests were performed to answer the following research question as “How do specific factors (work environment, performance, behavior, problem-solving and transformational role) contribute to nursing leadership in Mongolia?”

The finding of this study says that two of the variables, namely, behavior and problem-solving, positively contribute to nursing leadership and nurses' perceptions of their leader's effectiveness. This means that this study supports two out of the five hypotheses and does not support three hypotheses. The results suggest that an individual behavior and characteristics (problem-solving ability and the transformational role) strongly reflect leadership. In contrast, the reflection of external variables depends on the profession and specialty, as nurses have a high workload; therefore, work environment and performance do not contribute to the nursing leadership.

The nurse department consists of nurses with different types of behaviors, but individual behavior affects the outcome of the nurse leadership. Registered Nurses' Association ( 33 )'s guideline states that the individual behavior of a leader is important, but, also, the culture, climate, and values of organizations are essential to building the behavior of an individual. Since nursing research is not common in Mongolia, it is necessary to explore the way how behavior influences nursing leadership and, in turn, how the behavior of the nurse leadership influences the organizational outcome.

What Are the Multiple Correlations Between the Predictors (Work Environment, Performance, Behavior, Problem-Solving, and Transformational Ability) and the Nursing Leadership?

The multiple regression performed in this study indicated 83% of the variance in nursing leadership was accounted for by the linear combinations of work environment, performance, behavior, problem-solving, and the transformational role. Therefore, it is important to explore variable factors to impact nursing leadership in hospital settings in Mongolia.

The results in this study revealed a positive correlation existed between the dependent variable, nursing leadership, and three independent variables, behavior, problem-solving, and the transformational role. Behavior reflected the strongest correlation, followed by perceived problem-solving and the transformational role of nursing leadership. This means that nurse leaders should accurately anticipate and prevent misunderstanding and conflicts, redefine the goals of nurse managers, develop new medical techniques, and facilitate desirable strategic decision-making.

Registered Nurses' Association ( 33 ) identified that there is a growing understanding of the relationship between nurses' work environment, patients' outcomes, and healthcare institutions' performances. However, our study did not confirm that the work environment influences nurse leadership. Moreover, there is some research on the direct impact of the work environment on developing and sustaining nursing leadership. Nurse manager turnover is usually associated with a range of negative outcomes, including training new nurses, increased workload, and the salary range.

This research suggests that gender roles are higher from their management identity as nurse managers in hospital settings. For those who evaluate the competence and effectiveness of nursing leadership in hospital settings that are mostly female, the data suggest that females may be more effective leaders since females are more likely to practice a transformational role. This is a very important implication in order to develop a policy framework for health care settings.

Why Do We Need to Study Factors Contributing to the Sustainability of Nursing Leadership?

When we know the factors that contribute to nursing leadership, healthcare institutions are able to develop leadership styles among nurses in the nursing department. The study increases the effectiveness of current nurse managers and guides the identification of future nurse leaders.

Currently, in Mongolian hospitals, almost more than 50 percent of nurse managers' performances spent for administrative work include making a list of all the prescription drugs, counting the number of beds and linens in a hospital, and monitoring shift change of nurse staffs. Therefore, very few percentages of performances are spent on hospital care. Thus, performance was not contributed to the nurse leader in the Mongolian case. In the future, it must change the nurse manager's role that enables high performance for quality care of patients and hospital care.

Moreover, nurse managers experience a higher workload than ever before due to several reasons, although the work environment does not support nurse leadership. The reasons are, first, hospitals do not have online patient registration; therefore, the nurse managers fill out all registration forms by hand, and, hence, they spend most of their working hours in the workplace. Second, there is no consolidated database of nurse performance within hospitals, compared to the physicians. For instance, hospitals have an integrated database for all physicians; however, neither nurse managers nor nurses have an integrated database. Third, the high workload of nurse managers does not allow training other nurse staff due to shortage of time. Finally, there is a lack of technology, including the internet environment and patient care resources.

The specialty nursing expertise is generally obtained on the job, also through nursing programs to attract new graduate nurses and motivate them further in nursing leadership. In Mongolia, around 1,000 nurses graduate from the National Medical University and its three branches, and private three universities per year. Nursing leadership programs must be offered through undergraduate and graduate education in formal and informal ways. Unfortunately, currently, nursing leadership programs are offered neither by universities nor hospitals. High school graduates are less likely to major by the nurse due to low reputation and low career development. Moreover, promoting higher education to nurses of all educational levels is critical to developing nurse leadership in hospital settings. Hence, another main reason that why the work environment and performance of nurse managers do not support our hypotheses.

How Does Nurses' Role Function Transfer to a Leadership Role in the Hospital Care Delivery System?

Nurse managers' autonomy over decisions affects the work at the unit level, patient care services, and health care institutions' commitment. When nurse leadership is high among nurses, nurse managers feel empowered and influential not only in their current role but also regarding impacts on nursing staff.

Leadership is rewarding and important for building succession, and it is a significant level of commitment to a job ( 18 ). But, in the Mongolian case, it is controversial as nurses are at the same level as kindergarten teachers and elementary school teachers; unfortunately, their salary range is lower than theirs. A nurse manager earns only one percent higher salary than nurses; however, less-experienced nurse managers have the same salary range as nurses. Therefore, the performances of nurse managers that are weak, do not motivate them to be leaders. In the last few years, the education level of nurse managers has been increased, and almost 50 percent of nurses have a bachelor's degree. However, the higher education level does not increase salary.

Promotion is not common among nurse managers and nurses that raise a negative impact to nurse performance and nurse leadership. The performance assessment is not clear in hospital settings. The nurse service quality is far away from the international standards; therefore, patients have more complaints on nurse performance, which directly affects nursing leadership. Quality of care is based on confidence and competence, which nurse leaders need support now more than ever.

Physicians and doctors do not recognize the nurse leadership role in patient care service and do not have the legal environment to support the nurse manager's performance and work environment.

Is Nursing Leadership Essential for a Hospital? If Yes, How?

The nurse staff is working longer hours and taking an increased patient assignment. Moreover, job satisfaction highly reflects nurse turnover. Therefore, involving nurse staff at a high level in policy and procedure development will score high on the retention scale and motivate nurse leadership among nurse managers in hospital settings. Moreover, strengthening nursing leadership is particularly critical not only in nursing and medicine but also in society.

Head nurses and director nurses include the members of management of a hospital; indeed, they must be involved in decision-making for patient care and policy development of an organizational structure. Unfortunately, nurse managers have a weak nurse leadership role, which cannot reflect strong policy development in a whole organizational setting.

Overall, these results suggest an important role of nurse leadership in strengthening hospital development and patient care services in hospital settings. The nursing unit must set behavioral standards, problem-solving approaches, and transformational roles among nurses that most positively influence the nursing leadership. On the other hand, the external variables, as work environment and performance, have to reflect the demanding role of today's nurse managers at the surface level of a hospital.


The data were gathered using a self-report questionnaire, like the majority of earlier studies, and no objective measures were used. Self-report data might be contaminated by common method variance because five independent variables and dependent variables are based upon one source of information. Nevertheless, this study has stated that leadership has a strong and positive impact regardless of whether outcomes are measured subjectively or objectively.

Future studies need to identify the work environment and performance of nurses in the hospital settings in regard to nursing populations.


Health care organizations must invest in educational programs to develop leadership competencies in the workplaces to enhance their roles. Accordingly, the Ministry of Health of Mongolia must organize fruitful leadership programs in that nurses and new graduates should be encouraged to develop a strong and well-structured knowledge base in the context of their discipline. The curriculum should make an explicit reference to the international experience base and further development of nurses.

Nurse managers must have the higher professional expertise to sustain nursing leadership comparing nurse staff; however, there are no criteria between nurse managers and nurse staff to compare the effectiveness of leadership roles. An online database of nurses and nurse managers must be developed, and promotional activities are vital for effective nursing leadership.

Recently, the educational level of nurses has been increased, but there are no differences in terms of reference between position levels of nurses. The key recommendation is for the reinvention of nursing education and work environments to address and appeal to the needs and values of a new generation of nurses and enhance the quality of patient care.

Effective nursing practice, education, research, and leadership are grounded in the complexity of human relationships and, therefore, require systematic and careful thinking in order to achieve successful outcomes of nurse performance. A hospital organizational structure must allow having a voice in policymaking for nursing service and patient care. We need a stronger model for developing and grooming nurse leaders. The nurse career model must include differential salary ranges between nurses and nurse managers that positively impact nursing leadership.

Currently, the basic techniques in hospitals are very old, and they must change the techniques in a complex way and renovate the hospital buildings, which can impact the work environment and enhance patient care services. Unfortunately, due to financial shortage, Government is not able to support hospitals, which has negative reflects on nursing leadership. The supply of hospital equipment and linens is not sufficient for hospital settings; therefore, we have widely recognized the quality of supply apart from product quality that strengths the work environment of nurses and, moreover, impacts the nursing leadership.

The policy of hospitals has greater uncertainty and ambiguity; therefore, in the forthcoming years, we will likely see greater revision and practical approaches to promote nursing leadership. Moreover, it is necessary to collectively determine the purpose of nursing leadership and to make changes in our healthcare systems that positively impact patient care services. This guiding purpose will help us determine what we are likely to do, and where we are likely to go from here. Our paper applies descriptive and correlation analysis and employs multiple linear regression models to examine nurse management and patient care services. Extensions of our paper include using our approach to examine food waste reduction ( 35 , 36 ), network analysis ( 37 ), carbon emissions ( 38 ), procurement system ( 39 ), and many others. Readers may read Wong ( 40 ) for other areas in that academics and practitioners could apply the approach used in our paper for their studies. This paper studies the sustainability of nursing leadership; scholars can apply the approach used in this paper to study the sustainability of herding behavior (( 41 )), portfolio selection ( 42 ), organizational climate and work style ( 43 ), supply chains ( 44 ), health insurance ( 45 ), and many others.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

Ethical review and approval was not required for this study in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author Contributions

BW, DD, and M-UB: conceptualization. BW: methodology. DD: data curation and writing—original draft. BW and DD: formal analysis. W-KW: supervision. M-UB and OS: writing—review and editing and funding acquisition. W-KW and M-UB: project administration. All authors contributed to the article and approved the submitted version.

This research was supported by Chinese Academy of Medical Sciences and Peking Union Medical College, China (Grant number: 2021-RC630-001), National University of Mongolia, Asia University, China Medical University Hospital, The Hang Seng University of Hong Kong, Research Grants Council (RGC) of Hong Kong (project numbers 12502814 and 12500915), and the Ministry of Science and Technology (MOST, Project Numbers 106-2410-H-468-002 and 107-2410-H-468-002-MY3), Taiwan. However, any remaining errors are solely ours.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The authors thank the Editor-in-Chief and the referees for their helpful comments which help to improve our manuscript significantly. W-KW would like to thank Robert B. Miller and Howard E. Thompson for their continuous guidance and encouragement.

Supplementary Material

The Supplementary Material for this article can be found online at:

1. Nehls N. Recovering: a process of empowerment. Adv Nurs Sci. (2000) 22:62–70. doi: 10.1097/00012272-200006000-00006

PubMed Abstract | CrossRef Full Text | Google Scholar

2. Al-Husami M. A study of nurses' job satisfaction: the relationship to organizational commitment, perceived organizational support, transactional leadership, transformational leadership, and level of education. Eur J Sci Res. (2008) 22:286–95.

Google Scholar

3. Rajbhandary S, Basu K. Working conditions of nurses and absenteeism: is there a relationship? An empirical analysis using National Survey of the Work and Health of Nurses. Health Policy. (2010) 97:152–9. doi: 10.1016/j.healthpol.2010.04.010

4. Gaalan K, Kunaviktikul W, Akkadechanunt T, Wichaikhum OA, Turale S. Factors predicting quality of nursing care among nurses in tertiary care hospitals in Mongolia. Int Nurs Rev. (2019) 66:176–82. doi: 10.1111/inr.12502

5. Ramey JW. The Relationship Between Leadership Styles of Nurse Managers and Staff Nurse Job Satisfaction in Hospital Settings . West Virginia: Marshall University College of Nursing and Health Professions Huntington (2002).

6. Casida JM. The Relationship of Nurse Manager's Leadership Styles and Nursing Unit Organizational Culture in Acute Care Hospitals in New Jersey . South Orange, NJ: Seton Hall University (2007).

7. Aiken LH, Sloane D, Griffiths P, Rafferty AM, Bruyneel L, McHugh M, et al. Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual Saf. (2017) 26:559–68. doi: 10.1136/bmjqs-2016-005567

8. Furukawa P, Cunha ICKO. Profile and competencies of nurse managers at accredited hospitals. Rev Lat Am Enfermagem. (2011) 19:106–14. doi: 10.1590/S0104-11692011000100015

9. Koy V, Yunibhand J, Angsuroch Y, Fisher ML. Relationship between nursing care quality, nurse staffing, nurse job satisfaction, nurse practice environment, and burnout: literature review. Int J Res Med Sci. (2015) 3:1825–31. doi: 10.18203/2320-6012.ijrms20150288

CrossRef Full Text | Google Scholar

10. Jenkins M, Stewart AC. The importance of a servant leader orientation. Health Care Manage Rev. (2010) 35:46–54. doi: 10.1097/HMR.0b013e3181c22bb8

11. Schreuder JAH, Roelen CAM, van Zweeden NF, Jongsma D, van der Klink JJL, Groothoff JW. Leadership styles of nurse managers and registered sickness absence among their nursing staff. Health Care Manage Rev. (2011) 36:58–66. doi: 10.1097/HMR.0b013e3181edd96b

12. Al-Hamdan Z, Shukri R, Anthony D. Conflict management styles used by nurse managers in the Sultanate of Oman. J. Clin. Nurs. (2011) 20:571–80. doi: 10.1111/j.1365-2702.2010.03557.x

13. Olds DM, Aiken LH, Cimiotti JP, Lake ET. Association of nurse work environment and safety climate on patient mortality: a cross-sectional study. Int J Nurs Stud. (2017) 74:155–61. doi: 10.1016/j.ijnurstu.2017.06.004

14. Tsogbadrakh B., Akkadechanunt T., Chontawan R. (2016). Team climate and quality nursing care among nurses in tertiary care hospitals, Mongolia. Nurs J Chiang Mai Univ. 43–118.

15. World Bank. (2020). Databank of Mongolia . Available online at: (accessed May 25, 2020).

16. Batmunkh MU, Choijil E, Vieito JP, Espinosa-Méndez C, Wong WK. Does herding behavior exist in the Mongolian stock market? Pacific-Basin Finance J. (2020) 62:101352. doi: 10.1016/j.pacfin.2020.101352

17. Ministry of Health of Mongolia. (2012). Health Indicators . Ulaanbaatar: Soyombo Printing.

18. Tsai CW, Tsai SH, Chen YY, Lee WL. A study of nursing competency, career self-efficacy and professional commitment among nurses in Taiwan. Contemp Nurse. (2014) 49:96–102. doi: 10.1080/10376178.2014.11081959

19. Kouzes JM, Posner BZ. The Leadership Challenge: How to Keep Getting Things Done in Organizations. San Francisco: CA: Jossey – Bass. (1995).

20. Liu Y. Nurses' work role in the context of gender and Chinese culture: an online forum study. J Nurs Res. (2010) 18:117–25. doi: 10.1097/JNR.0b013e3181dda76a;

21. Ma C, Olds DM, Dunton NE. Nurse work environment and quality of care by unit types: a cross-sectional study. Int J Nurs Stud. (2015) 52:1565–72. doi: 10.1016/j.ijnurstu.2015.05.011

22. Cummings G, Lee H, MacGregor T, Davey M, Wong C, Paul L, et al. Factors contributing to nursing leadership: a systematic review. J Health Serv Res Policy. (2008) 13:240–8. doi: 10.1258/jhsrp.2008.007154

23. Huang LC, Lee JL, Liang YW, Hsu MY, Cheng JF, Mei TT. The skill mix model: a preliminary study of changing nurse role functions in Taiwan. J Nurs Res. (2011) 19:220–9. doi: 10.1097/JNR.0b013e318228cd5d

24. James SV, Kotzé WJ, Van Rooyen D. The relationship experiences of professional nurses with nurse managers. Health SA Gesondheid. (2005) 10:4–14. doi: 10.4102/hsag.v10i1.184

25. Nilsson J, Johansson E, Egmar AC, Florin J, Leksell J, Lepp M, et al. Development and validation of a new tool measuring nurses self-reported professional competence—The nurse professional competence (NPC) Scale. Nurse Educ Today. (2014) 34:574–80. doi: 10.1016/j.nedt.2013.07.016

26. Chu CI, Hsu YF. Hospital nurse job attitudes and performance: the impact of employment status. J Nurs Res. (2011) 19:53–60. doi: 10.1097/JNR.0b013e31820beba9

27. Duffield CM, Roche MA, Blay N, Stasa H. Nursing unit managers, staff retention and the work environment. J Clin Nurs. (2011) 20:23–33. doi: 10.1111/j.1365-2702.2010.03478.x

28. Healy CM, McKay MF. Nursing stress: the effects of coping strategies and job satisfaction in a sample of Australian nurses. J Adv Nurs. (2000) 31:681–8. doi: 10.1046/j.1365-2648.2000.01323.x

29. Meeusen VC, Van Dam K, Brown-Mahoney C, Van Zundert AA, Knape HT. Understanding nurse anesthetists' intention to leave their job: how burnout and job satisfaction mediate the impact of personality and workplace characteristics. Health Care Manage Rev. (2011) 36:155–63. doi: 10.1097/HMR.0b013e3181fb0f41

30. Gowen CR III, Henagan SC, McFadden KL. Knowledge management as a mediator for the efficacy of transformational leadership and quality management initiatives in US health care. Health Care Manag Rev. (2009) 34:129–40. doi: 10.1097/HMR.0b013e31819e9169

31. Stichler JF. The Effects of Collaboration, Organizational Climate, and Job Stress on Job Satisfaction and Anticipated Turnover in Nursing . (1990).

32. Krugman M, Smith V. Charge nurse leadership development and evaluation. J Nurs Adm. (2003) 33:284–92. doi: 10.1097/00005110-200305000-00004

33. Registered Nurses' Association (32). Developing and Sustaining Nursing Leadership . Toronto, ON: Registered Nurses' Association of Ontario.

34. Pillay R. Work satisfaction of professional nurses in South Africa: a comparative analysis of the public and private sectors. Hum Resour Health. (2009) 7:1–10. doi: 10.1186/1478-4491-7-15

35. Attiq S, Chau KY, Bashir S, Habib MD, Azam RI, Wong WK. Sustainability of household food waste reduction: A fresh insight on youth's emotional and cognitive behaviors. Int J Environ Res Public Health. (2021) 18:7013. doi: 10.3390/ijerph18137013

36. Attiq S, Chu AM, Azam RI, Wong WK, Mumtaz S. Antecedents of consumer food waste reduction behavior: psychological and financial concerns through the lens of the theory of interpersonal behavior. Int J Environ Res Public Health. (2021) 18:12457. doi: 10.3390/ijerph182312457

37. Chu AM, Chan TW, So MK, Wong WK. Dynamic network analysis of COVID-19 with a latent pandemic space model. Int J Environ Res Public Health. (2021) 18:3195. doi: 10.3390/ijerph18063195

38. Lv Z, Chu AM, McAleer M, Wong WK. Modelling economic growth, carbon emissions, and fossil fuel consumption in china: Cointegration and multivariate causality. Int J Environ Res Public Health . (2019) 16:4176. doi: 10.3390/ijerph16214176

39. Pentrakan A, Yang CC, Wong WK. How well does a sequential minimal optimization model perform in predicting medicine prices for procurement system? Int J Environ Res Public Health . (2021) 18:5523. doi: 10.3390/ijerph18115523

40. Wong WK. Review on behavioral economics and behavioral finance. Stud Econ Finance. (2020) 37:625–72. doi: 10.1108/SEF-10-2019-0393

41. Munkh-Ulzii B. J., McAleer M., Moslehpour M., Wong W. K. (2018). Confucius and herding behaviour in the stock markets in China and Taiwan. Sustainability , 10:4413. doi: 10.3390/su10124413

42. Li ZX, Li XG, Hui YC, Wong WK. Maslow portfolio selection for individuals with low financial sustainability. Sustainability. (2018) 10:28. doi: 10.3390/su10041128

43. Moslehpour M, Altantsetseg P, Mou WM, Wong WK. Organizational climate and work style: the missing links for sustainability of leadership and satisfied employees. Sustainability. (2019) 11:125. doi: 10.3390/su11010125

44. Mou WM, Wong WK, McAleer M. Financial credit risk evaluation based on core enterprise supply chains. Sustainability. (2018) 10:3699. doi: 10.3390/su10103699

45. Tsendsuren S, Chu-Shiu Li CS, Peng SC, Wong WK. The effects of health status on life insurance holdings in 16 European countries. Sustainability. (2018) 10:3454. doi: 10.3390/su10103454

Keywords: nurse leadership, work environment, performance, problem-solving, transformational role

Citation: Wang B-L, Batmunkh M-U, Samdandash O, Divaakhuu D and Wong W-K (2022) Sustainability of Nursing Leadership and Its Contributing Factors in a Developing Economy: A Study in Mongolia. Front. Public Health 10:900016. doi: 10.3389/fpubh.2022.900016

Received: 23 March 2022; Accepted: 07 April 2022; Published: 25 May 2022.

Reviewed by:

Copyright © 2022 Wang, Batmunkh, Samdandash, Divaakhuu and Wong. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Wing-Keung Wong,

This article is part of the Research Topic

Asian Health Sectors Growth in the Next Decade - Optimism despite Challenges Ahead

Fastest Nurse Insight Engine

Making Decisions and Solving Problems

CHAPTER 6 Making Decisions and Solving Problems Rose Aguilar Welch This chapter describes the key concepts related to problem solving and decision making. The primary steps of the problem-solving and decision-making processes, as well as analytical tools used for these processes, are explored. Moreover, strategies for individual or group problem solving and decision making are presented. Objectives •  Apply a decision-making format to list options to solve a problem, identify the pros and cons of each option, rank the options, and select the best option. •  Evaluate the effect of faulty information gathering on a decision-making experience. •  Analyze the decision-making style of a nurse leader/manager. •  Critique resources on the Internet that focus on critical thinking, problem solving, and decision making. Terms to Know autocratic creativity critical thinking decision making democratic optimizing decision participative problem solving satisficing decision The Challenge Vickie Lemmon RN, MSN Director of Clinical Strategies and Operations, WellPoint, Inc., Ventura, California Healthcare managers today are faced with numerous and complex issues that pertain to providing quality services for patients within a resource-scarce environment. Stress levels among staff can escalate when problems are not resolved, leading to a decrease in morale, productivity, and quality service. This was the situation I encountered in my previous job as administrator for California Children Services (CCS). When I began my tenure as the new CCS administrator, staff expressed frustration and dissatisfaction with staffing, workload, and team communications. This was evidenced by high staff turnover, lack of teamwork, customer complaints, unmet deadlines for referral and enrollment cycle times, and poor documentation. The team was in crisis, characterized by in-fighting, blaming, lack of respectful communication, and lack of commitment to program goals and objectives. I had not worked as a case manager in this program. It was hard for me to determine how to address the problems the staff presented to me. I wanted to be fair but thought that I did not have enough information to make immediate changes. My challenge was to lead this team to greater compliance with state-mandated performance measures. What do you think you would do if you were this nurse? Introduction Problem solving and decision making are essential skills for effective nursing practice. Carol Huston (2008) identified “expert decision-making skills” as one of the eight vital leadership competencies for 2020. These processes not only are involved in managing and delivering care but also are essential for engaging in planned change. Myriad technologic, social, political, and economic changes have dramatically affected health care and nursing. Increased patient acuity, shorter hospital stays, shortage of healthcare providers, increased technology, greater emphasis on quality and patient safety, and the continuing shift from inpatient to ambulatory and home health care are some of the changes that require nurses to make rational and valid decisions. Moreover, increased diversity in patient populations, employment settings, and types of healthcare providers demands efficient and effective decision making and problem solving. More emphasis is now placed on involving patients in decision making and problem solving and using multidisciplinary teams to achieve results. Nurses must possess the basic knowledge and skills required for effective problem solving and decision making. These competencies are especially important for nurses with leadership and management responsibilities. Definitions Problem solving and decision making are not synonymous terms. However, the processes for engaging in both processes are similar. Both skills require critical thinking, which is a high-level cognitive process, and both can be improved with practice. Decision making is a purposeful and goal-directed effort that uses a systematic process to choose among options. Not all decision making begins with a problem situation. Instead, the hallmark of decision making is the identification and selection of options or alternatives. Problem solving, which includes a decision-making step, is focused on trying to solve an immediate problem, which can be viewed as a gap between “what is” and “what should be.” Effective problem solving and decision making are predicated on an individual’s ability to think critically. Although critical thinking has been defined in numerous ways, Scriven and Paul (2007) refer to it as “ the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.” Effective critical thinkers are self-aware individuals who strive to improve their reasoning abilities by asking “why,” “what,” or “how.” A nurse who questions why a patient is restless is thinking critically. Compare the analytical abilities of a nurse who assumes a patient is restless because of anxiety related to an upcoming procedure with those of a nurse who asks if there could be another explanation and proceeds to investigate possible causes. It is important for nurse leaders and managers to assess staff members’ ability to think critically and enhance their knowledge and skills through staff-development programs, coaching, and role modeling. Establishing a positive and motivating work environment can enhance attitudes and dispositions to think critically. Creativity is essential for the generation of options or solutions. Creative individuals can conceptualize new and innovative approaches to a problem or issue by being more flexible and independent in their thinking. It takes just one person to plant a seed for new ideas to generate . The model depicted in Figure 6-1 demonstrates the relationship among related concepts such as professional judgment, decision making, problem solving, creativity, and critical thinking. Sound clinical judgment requires critical or reflective thinking. Critical thinking is the concept that interweaves and links the others. An individual, through the application of critical-thinking skills, engages in problem solving and decision making in an environment that can promote or inhibit these skills. It is the nurse leader’s and manager’s task to model these skills and promote them in others. FiGURE 6-1 Problem-solving and decision-making model. Decision Making This section presents an overview of concepts related to decision models, decision-making styles, factors affecting decision making, group decision making (advantages and challenges), and strategies and tools. The phases of the decision-making process include defining objectives, generating options, identifying advantages and disadvantages of each option, ranking the options, selecting the option most likely to achieve the predefined objectives, implementing the option, and evaluating the result. Box 6-1 contains a form that can be used to complete these steps. BOX 6-1    Decision-Making Format Objective: _____________________________________ Options Advantages Disadvantages Ranking                                 Add more rows as necessary. Rank priority of options, with “1” being most preferred. Select the best option. Implementation plan: ______________________________________________________________________________ Evaluation plan: __________________________________________________________________________________ A poor-quality decision is likely if the objectives are not clearly identified or if they are inconsistent with the values of the individual or organization. Lewis Carroll illustrates the essential step of defining the goal, purpose, or objectives in the following excerpt from Alice’s Adventures in Wonderland: One day Alice came to a fork in the road and saw a Cheshire Cat in a tree. “Which road do I take?” she asked. His response was a question: “Where do you want to go?” “I don’t know,” Alice answered. “Then,” said the cat, “it doesn’t matter.” Decision Models The decision model that a nurse uses depends on the circumstances. Is the situation routine and predictable or complex and uncertain? Is the goal of the decision to make a decision conservatively that is just good enough or one that is optimal? If the situation is fairly routine, nurse leaders and managers can use a normative or prescriptive approach. Agency policy, standard procedures, and analytical tools can be applied to situations that are structured and in which options are known. If the situation is subjective, non-routine, and unstructured or if outcomes are unknown or unpredictable, the nurse leader and manager may need to take a different approach. In this case, a descriptive or behavioral approach is required. More information will need to be gathered to address the situation effectively. Creativity, experience, and group process are useful in dealing with the unknown. In the business world, Camillus described complex problems that are difficult to describe or resolve as “wicked” (as cited in Huston, 2008). This term is apt in describing the issues that nurse leaders face. In these situations, it is especially important for nurse leaders to seek expert opinion and involve key stakeholders. Another strategy is satisficing. In this approach, the decision maker selects the solution that minimally meets the objective or standard for a decision. It allows for quick decisions and may be the most appropriate when time is an issue. Optimizing is a decision style in which the decision maker selects the option that is best, based on an analysis of the pros and cons associated with each option. A better decision is more likely using this approach, although it does take longer to arrive at a decision. For example, a nursing student approaching graduation is contemplating seeking employment in one of three acute care hospitals located within a 40-mile radius of home. The choices are a medium-size, not-for-profit community hospital; a large, corporate-owned hospital; and a county facility. A satisficing decision might result if the student nurse picked the hospital that offered a decent salary and benefit packet or the one closest to home. However, an optimizing decision is more likely to occur if the student nurse lists the pros and cons of each acute care hospital being considered such as salary, benefits, opportunities for advancement, staff development, and mentorship programs. Decision-Making Styles The decision-making style of a nurse manager is similar to the leadership style that the manager is likely to use. A manager who leans toward an autocratic style may choose to make decisions independent of the input or participation of others. This has been referred to as the “decide and announce” approach, an authoritative style. On the other hand, a manager who uses a democratic or participative approach to management involves the appropriate personnel in the decision-making process. It is imperative for managers to involve nursing personnel in making decisions that affect patient care. One mechanism for doing so is by seeking nursing representation on various committees or task forces. Participative management has been shown to increase work performance and productivity, decrease employee turnover, and enhance employee satisfaction. Any decision style can be used appropriately or inappropriately. Like the tenets of situational leadership theory, the situation and circumstances should dictate which decision-making style is most appropriate. A Code Blue is not the time for managers to democratically solicit volunteers for chest compressions! The autocratic method results in more rapid decision making and is appropriate in crisis situations or when groups are likely to accept this type of decision style. However, followers are generally more supportive of consultative and group approaches. Although these approaches take more time, they are more appropriate when conflict is likely to occur, when the problem is unstructured, or when the manager does not have the knowledge or skills to solve the problem. Exercise 6-1 Interview colleagues about their most preferred decision-making model and style. What barriers or obstacles to effective decision making have your colleagues encountered? What strategies are used to increase the effectiveness of the decisions made? Based on your interview, is the style effective? Why or why not? Factors Affecting Decision Making Numerous factors affect individuals and groups in the decision-making process. Tanner (2006) conducted an extensive review of the literature to develop a Clinical Judgment Model. Out of the research, she concluded that five principle factors influence decision making. (See the Literature Perspective below.) Literature Perspective Resource: Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45 (6), 204-211. Tanner engaged in an extensive review of 200 studies focusing on clinical judgment and clinical decision making to derive a model of clinical judgment that can be used as a framework for instruction. The first review summarized 120 articles and was published in 1998. The 2006 article reviewed an additional 71 studies published since 1998. Based on an analysis of the entire set of articles, Tanner proposed five conclusions which are listed below. The reader is referred to the article for detailed explanation of each of the five conclusions. The author considers clinical judgment as a “problem-solving activity.” She notes that the terms “clinical judgment,” “problem solving,” “decision making,” and “critical thinking” are often used interchangeably. For the purpose of aiding in the development of the model, Tanner defined clinical judgment as actions taken based on the assessment of the patient’s needs. Clinical reasoning is the process by which nurses make their judgments (e.g., the decision-making process of selecting the most appropriate option) (Tanner, 2006, p. 204): 1.  Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand. 2.  Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns. 3.  Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit. 4.  Nurses use a variety of reasoning patterns alone or in combination. 5.  Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. The Clinical Judgment Model developed through the review of the literature involves four steps that are similar to problem-solving and decision-making steps described in this chapter. The model starts with a phase called “Noticing.” In this phase, the nurse comes to expect certain responses resulting from knowledge gleaned from similar patient situations, experiences, and knowledge. External factors influence nurses in this phase such as the complexity of the environment and values and typical practices within the unit culture. The second phase of the model is “Interpreting,” during which the nurse understands the situation that requires a response. The nurse employs various reasoning patterns to make sense of the issue and to derive an appropriate action plan. The third phase is “Responding,” during which the nurse decides on the best option for handling the situation. This is followed by the fourth phase, “Reflecting,” during which the nurse assesses the patient’s responses to the actions taken. Tanner emphasized that “reflection-in-action” and “reflection-on-action” are major processes required in the model. Reflection-in-action is real-time reflection on the patient’s responses to nursing action with modifications to the plan based on the ongoing assessment. On the other hand, reflection-on-action is a review of the experience, which promotes learning for future similar experiences. Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. As Tanner (2006) so eloquently concludes, “If we, as nurse educators, help our students understand and develop as moral agents, advance their clinical knowledge through expert guidance and coaching, and become habitual in reflection-on-practice, they will have learned to think like a nurse” ( p. 210 ). Implications for Practice Nurse educators and managers can employ this model with new and experienced nurses to aid in understanding thought processes involved in decision making. For example, students and practicing nurses can be encouraged to maintain reflective journals to record observations and impressions from clinical experiences. In clinical post-conferences or staff development meetings, the nurse educator and manager can engage them in applying to their lived experiences the five conclusions Tanner proposed. The ultimate goal of analyzing their decisions and decision-making processes is to improve clinical judgment, problem-solving, decision-making, and critical-thinking skills. Internal and external factors can influence how the situation is perceived. Internal factors include variables such as the decision maker’s physical and emotional state, personal philosophy, biases, values, interests, experience, knowledge, attitudes, and risk-seeking or risk-avoiding behaviors. External factors include environmental conditions, time, and resources. Decision-making options are externally limited when time is short or when the environment is characterized by a “we’ve always done it this way” attitude. Values affect all aspects of decision making, from the statement of the problem/issue through the evaluation. Values, determined by one’s cultural, social, and philosophical background, provide the foundation for one’s ethical stance. The steps for engaging in ethical decision making are similar to the steps described earlier; however, alternatives or options identified in the decision-making process are evaluated with the use of ethical resources. Resources that can facilitate ethical decision making include institutional policy; principles such as autonomy, nonmaleficence, beneficence, veracity, paternalism, respect, justice, and fidelity; personal judgment; trusted co-workers; institutional ethics committees; and legal precedent. Certain personality factors, such as self-esteem and self-confidence, affect whether one is willing to take risks in solving problems or making decisions. Keynes (2008) asserts that individuals may be influenced based on social pressures. For example, are you inclined to make decisions to satisfy people to whom you are accountable or from whom you feel social pressure? Characteristics of an effective decision maker include courage, a willingness to take risks, self-awareness, energy, creativity, sensitivity, and flexibility. Ask yourself, “Do I prefer to let others make the decisions? Am I more comfortable in the role of ‘follower’ than leader? If so, why?” Exercise 6-2 Identify a current or past situation that involved resource allocation, end-of-life issues, conflict among healthcare providers or patient/family/significant others, or some other ethical dilemma. Describe how the internal and external factors previously described influenced the decision options, the option selected, and the outcome. Group Decision Making There are two primary criteria for effective decision making. First, the decision must be of a high quality; that is, it achieves the predefined goals, objectives, and outcomes. Second, those who are responsible for its implementation must accept the decision. Higher-quality decisions are more likely to result if groups are involved in the problem-solving and decision-making process. In reality, with the increased focus on quality and safety, decisions cannot be made alone. When individuals are allowed input into the process, they tend to function more productively and the quality of the decision is generally superior. Taking ownership of the process and outcome provides a smoother transition. Multidisciplinary teams should be used in the decision-making process, especially if the issue, options, or outcome involves other disciplines. Research findings suggest that groups are more likely to be effective if members are actively involved, the group is cohesive, communication is encouraged, and members demonstrate some understanding of the group process. In deciding to use the group process for decision making, it is important to consider group size and composition. If the group is too small, a limited number of options will be generated and fewer points of view expressed. Conversely, if the group is too large, it may lack structure, and consensus becomes more difficult. Homogeneous groups may be more compatible; however, heterogeneous groups may be more successful in problem solving. Research has demonstrated that the most productive groups are those that are moderately cohesive. In other words, divergent thinking is useful to create the best decision. For groups to be able to work effectively, the group facilitator or leader should carefully select members on the basis of their knowledge and skills in decision making and problem solving. Individuals who are aggressive, are authoritarian, or manifest self-oriented behaviors tend to decrease the effectiveness of groups. The nurse leader or manager should provide a nonthreatening and positive environment in which group members are encouraged to participate actively. Using tact and diplomacy, the facilitator can control aggressive individuals who tend to monopolize the discussion and can encourage more passive individuals to contribute by asking direct, open-ended questions. Providing positive feedback such as “You raised a good point,” protecting members and their suggestions from attack, and keeping the group focused on the task are strategies that create an environment conducive to problem solving. Advantages of Group Decision Making The advantages of group decision making are numerous. The adage “two heads are better than one” illustrates that when individuals with different knowledge, skills, and resources collaborate to solve a problem or make a decision, the likelihood of a quality outcome is increased. More ideas can be generated by groups than by individuals functioning alone. In addition, when followers are directly involved in this process, they are more apt to accept the decision, because they have an increased sense of ownership or commitment to the decision. Implementing solutions becomes easier when individuals have been actively involved in the decision-making process. Involvement can be enhanced by making information readily available to the appropriate personnel, requesting input, establishing committees and task forces with broad representation, and using group decision-making techniques. The group leader must establish with the participants what decision rule will be followed. Will the group strive to achieve consensus, or will the majority rule? In determining which decision rule to use, the group leader should consider the necessity for quality and acceptance of the decision. Achieving both a high-quality and an acceptable decision is possible, but it requires more involvement and approval from individuals affected by the decision. Groups will be more committed to an idea if it is derived by consensus rather than as an outcome of individual decision making or majority rule. Consensus requires that all participants agree to go along with the decision. Although achieving consensus requires considerable time, it results in both high-quality and high-acceptance decisions and reduces the risk of sabotage. Majority rule can be used to compromise when 100% agreement cannot be achieved. This method saves time, but the solution may only partially achieve the goals of quality and acceptance. In addition, majority rule carries certain risks. First, if the informal group leaders happen to fall in the minority opinion, they may not support the decision of the majority. Certain members may go so far as to build coalitions to gain support for their position and block the majority choice. After all, the majority may represent only 51% of the group. In addition, group members may support the position of the formal leader, although they do not agree with the decision, because they fear reprisal or they wish to obtain the leader’s approval. In general, as the importance of the decision increases, so does the percentage of group members required to approve it. To secure the support of the group, the leader should maintain open communication with those affected by the decision and be honest about the advantages and disadvantages of the decision. The leader should also demonstrate how the advantages outweigh the disadvantages, suggest ways the unwanted outcomes can be minimized, and be available to assist when necessary.

You may also need

problem solving nursing leadership

Share this:

Comments are closed for this page.

‘Ministers must recognise the vital role of school and public health nurses’


Thinking your way to successful problem-solving

13 September, 2001 By NT Contributor

VOL: 97, ISSUE: 37, PAGE NO: 36

Jacqueline Wheeler, DMS, MSc, RGN, is a lecturer at Buckinghamshire Chilterns University College

Problems - some people like them, some do not think they have any, while others shy away from them as if they were the plague. Opportunities, in the form of problems, are part of your life.

The most difficult decision is deciding to tackle a problem and implement a solution, especially as it is sometimes easier to ignore its existence. Problem-solving takes time and effort, but once a problem has been addressed the nurse can feel satisfied that the issue has been resolved and is therefore less likely to re-emerge.

Nurses make clinical decisions using two different approaches. The first is the rationalist approach, which involves an analysis of a situation so that subsequent actions are rational, logical and based on knowledge and judgement. The second approach is based on a phenomenological perspective, where a fluid, flexible and dynamic approach to decision-making is required, such as when dealing with an acutely ill patient.

Types of problems

Problems come in different guises and the solver can perceive them either as a challenge or a threat. One of the most common types of problem is when the unexpected happens. As a nurse you plan and implement care for a patient based on your knowledge and experience, only to find that the patient’s reaction is totally different from that expected but without any apparent reason.

Another type of problem is an assignment where others set a goal or task. Throughout your working life you will be required to undertake duties on behalf of other people. For some this is difficult as they feel unable to control their workload. Others see it as an opportunity to develop new skills or take on additional responsibilities. Opportunities can be perceived as problems by those who fear failure.

A third type of problem is when a dilemma arises. This is when it is difficult to choose the best solution to a problem because the nurse is confronted with something that challenges his or her personal and/or professional values.

Diagnosing problems

The sooner a problem is identified and solutions devised, the better for all involved. So try to anticipate or identify problems when they occur through continuously monitoring staff performance and patient outcomes.

Listening to and observing junior staff will help you to detect work or organisational concerns, because when there are problems staff are likely to behave in an unusual or inconsistent manner.

Initial analysis

Remember that people view things differently, so what you perceive as a problem may not be one to anyone else. So before you begin thinking about what to do - whether to keep it under surveillance, contain it or find a solution - you should undertake an initial analysis. This will help you to understand the problem more clearly.

An analysis will also enable you to prioritise its importance in relation to other problems as problems do not occur one at a time.

Routine problems often need little clarification, so an initial analysis is recommended for non-routine problems only. Even then, not all problems justify the same degree of analysis. But where it is appropriate, an initial analysis will provide a basis from which to generate solutions.

Perception is also important when dealing with patients’ problems. For example, if a patient gives up reading because he or she cannot hold the book (objective), the nurse may assume it is because the patient has lost interest (subjective, one’s own view).

Generating solutions

It is essential for the problem-solver to remember that, where possible, solutions must come from those connected with the problem. If it is to be resolved, agreement must be owned by those involved as they are probably the best and only people who can resolve their differences. The manager should never feel that he or she must be on hand to deal with all disputes.

To solve a problem you need to generate solutions. However, the obvious solution may not necessarily be the best. To generate solutions, a mixture of creative and analytical thinking is needed (Bransford, 1993).

Creativity is about escaping from preconceived ideas that block the way to finding an innovative solution to a problem. An effective tool for assisting in this process is the technique of lateral thinking, which is based largely on the work of Edward de Bono, who regards thinking as a skill.

There are several ways to encourage creative decision-making. One method that works best for specific or simple problems is brainstorming. If the ground rules of confidentiality and being non-judgemental are applied, it will produce a free flow of ideas generated without fear of criticism (Rawlinson, 1986).

Time constraints and staff availability may make it difficult for all those involved in a problem to meet. In such cases an adaptation of brainstorming - where a blank piece of paper is given to those involved and each writes down four solutions to the problem - may be the answer. A similar technique is the collective notebook, where people are asked to record their thoughts and ideas about a problem for a specified period.

An alternative is where one person writes down a list of solutions in order of priority, which is then added to by others. This helps to prioritise the ideas generated. All these methods produce data that can then be analysed by the problem-solver.

When the problem affects people in different geographical areas, solutions can be generated by obtaining the opinion of experts through the use of a questionnaire, which is known as the Delphi technique (McKenna, 1994).

When an apparently insurmountable problem presents itself, it is often useful to divide it into smaller pieces. This is known as convergent thinking. Using divergent thinking - where you consider a problem in different ways to expand your view - may also help. 

A final alternative is the stepladder technique, which is time-consuming but effective if the issue is stirring up strong feelings. This requires the people involved in the problem to be organised into groups. First, two people try to solve the problem, then a third member is drawn in, to whom the solution reached by the first two is presented. All three then try to agree a solution. More people are added to the group, if necessary, in a similar way, until there is agreement of all involved. Provided the individuals are motivated to solve the problem, this technique creates ownership and commitment to implementing the agreed solution.

Analytical thinking, which follows a logical process of eliminating ideas, will enable you to narrow the range down to one feasible solution.

Although someone has to make the ultimate decision on which solution to implement, there are advantages to group decision-making: a greater number of possible solutions are generated and conflicts are resolved, resulting in decisions being reached through rational discussion.

This does, however, require the group to be functioning well or the individuals involved may feel inhibited in contributing to the decision-making. One individual may dominate the group or competition between individuals may result in the need to win taking precedence over deciding on an agreed practical solution.

As nursing becomes less bureaucratic individuals are being encouraged to put forward their own ideas, but social pressures to conform may inhibit the group. We do not solve problems and make decisions in isolation, but are influenced by the environment in which we work and the role we fulfil in that environment. If group members lack commitment and/or motivation, they may accept the first solution and pay little attention to other solutions offered.

Making a decision

There are three types of decision-making environments: certain, risk and uncertain. The certain environment, where we have sufficient information to allow us to select the best solution, is the most comfortable within which to make a decision, but it is the least often encountered.

We usually encounter the risk environment, where we lack complete certainty about the outcomes of various courses of action.

Finally, the uncertain environment is the least comfortable within which to make decisions as we are almost forced to do this blind. We are unable to forecast the possible outcomes of alternative courses of action and, therefore, have to rely heavily on creative intuition and the educated guess.

Taking this into consideration, you should not contemplate making a decision until you have all the information needed. Before you make your decision, remind yourself of the objective, reassess the priorities, consider the options and weigh up the strengths, weaknesses, opportunities and threats of each solution.

An alternative is to use the method that Thomas Edison used to solve the problem of the electric light bulb. Simply focus on your problem as you drift off to sleep, and when you wake up your subconscious mind will have presented you with the answer. But bear in mind that this is not a scientific way of solving problems - your subconscious can be unreliable.

If you are not sure about your decision, test the solution out on others who do not own the problem but may have encountered a similar dilemma. Once you have made your choice stick to it, or you may find it difficult to implement because those involved will never be sure which solution is current. They will also be reluctant to become involved in any future decision-making because of your uncertainty.

The next step is to ensure that all the people involved know what decision has been made. Where possible, brief the group and follow this up with written communication to ensure everyone knows what is expected of them. You may need to sell the decision to some, especially if they were not involved in the decision-making process or the solution chosen is not theirs.

Implementing the solution

Finally, to ensure the solution is implemented, check that the people involved know who is to do what, by when and that it has happened. Review the results of implementing your solution (see Box) and praise and thank all those involved.

- Part 1 of this series was published in last week’s issue: Wheeler, J. (2001) How to delegate your way to a better working life. Nursing Times; 97: 36, 34-35.

Next week. Part three: a step-by-step guide to effective report writing.

Have your say

Sign in or Register a new account to join the discussion.

Home | About us | News | Courses | Virtual seminars | Contact us | Resources | This site was last updated March 12th 2015 by David Dawes


  1. ️ Problem solving skills in nursing. Problem solving skills in nursing home. 2019-01-05

    problem solving nursing leadership

  2. 6 Leadership Skills That Will Have You Solving Problems Like a Pro

    problem solving nursing leadership

  3. Defining Progressive Liberals.

    problem solving nursing leadership

  4. The effect of critical thinking education on nursing students’ problem-solving skills

    problem solving nursing leadership

  5. One less problem: Overview of problem-solving nursing apps 【Get Certified!】

    problem solving nursing leadership

  6. Credit Union Leadership Tips for Improving Performance and Problem-Solving

    problem solving nursing leadership


  1. NLM 200 Capstone Project by Lona Ong Narboada


  3. Cube Solving trick in 5sec#viralvideo #tiktok #shorts #tricks

  4. Introduction of Nursing Leadership and Community Nursing

  5. Nursing Students’ Critical Thinking, Problem Solving and Self Directive Learning Skills The Effect

  6. Mary Ellen O'Keefe Lifetime Achievement Award


  1. Nurse leaders as problem-solvers: Addressing lateral and hor

    The role of the nurse leader as a problem-solver should be clear, defined, and well supported to seek resolutions to toxic behaviors that are hurting the work

  2. Problem-Solving for Nurse Leaders

    Another valuable quality in leadership is being proactive in problem-solving. Good leaders handle issues as they arrive. They are capable of “

  3. Communication Skills, Problem-Solving Ability, Understanding of

    When effective communication takes place, nurses' problem-solving ... of critical thinking ability, communication skills, leadership

  4. Problem Solving Training for First Line Nurse Managers

    nurse managers' self-reported problem solving skills. ... leadership, staff management, and quality ... about problem solving in the field of nursing.

  5. Sustainability of Nursing Leadership and Its Contributing Factors in

    Problem-solving ability is one of the most important attributes for nurse managers to promote team integration to achieve maximum efficiency.

  6. Making Decisions and Solving Problems

    Problem solving and decision making are essential skills for effective nursing practice. Carol Huston (2008) identified “expert decision-making

  7. Critical thinking in Nursing: Decision-making and Problem-solving

    Explain multivoting and the prioritization matrix. • Discuss 7 steps to problem-solving. Introduction. As medicine becomes more and more complex and nursing.

  8. Thinking your way to successful problem-solving

    It is essential for the problem-solver to remember that, where possible, solutions must come from those connected with the problem. If it is to

  9. Test for problem-solving approach

    This test is designed to help you identify your preferred style for solving problems and is based on the work of Dr John Egger. It should take about 5 to 10

  10. Nursing leadership challenges and opportunities

    With the increasing complexity of health care, we need adaptive leadership approaches which critically analyze the complex problem-solving