Situational leadership theory in nursing management: a scoping review

The proliferation of international public health problems in recent years means a growing need for carers and a growing carer community [1]. Nursing teams can only be built with the nurse manager and nurses working together. The role of the nurse manager is to transform the organization’s culture and strategy into practical action at an operational level and to manage resources, coordinate care, plan and facilitate nursing care, and provide assessment services and support [2]. Leadership is the inner force that determines a leader’s leadership behavior and is the driving force that achieves group or organizational goals and ensures that the leading process runs smoothly [3]. Nursing leadership is the drive of nursing leaders to effectively bring followers together to establish and achieve their goals [4]. However, using a single leadership model may limit outcomes when faced with different aptitudes of nurses. To sustainably enable nurses to make progress and to improve the quality of nursing care and the efficiency of nursing management, more and more nurse managers use situational leadership theory as a guide. Using situational leadership theory helps nursing managers do this; management skills must also be involved. Situational leadership theory is valued in nursing management as a global applied leadership theory. It can provide a specific theoretical reference for nursing managers to explore practical ways to solve problems and construct evaluation standards for nurses. Situational leadership theory advocates that different leadership styles should be used when dealing with nurses with varying maturity levels to make management more effective [5]. However, with the gradual growth of the nursing team and the evolution of the theory, situational leadership theory has a variety of applications, approaches, and content in nursing management. Taking into account the problems and improvements in existing implementations can provide useful information for the future construction of intervention programs and facilitate further optimization. It is important to identify currently available nursing interventions and research gaps that need to be addressed.

Situational leadership theory was proposed and developed by Paul Hersey, a renowned psychologist and organizational behaviorist, and Kenneth Blanchard, a managerial scientist [5]. It is also known as the leadership life cycle theory, a theory of change that values subordinates. The theory suggests that leaders should adopt a leadership style appropriate to their team members’ abilities and willingness [6]. The situational leadership model reduces the factors that influence the effectiveness of leadership behavior to three: employee maturity, the leader’s task behavior, and the leader’s relationship behavior. The theory suggests that there is no single optimal leadership style, but rather that leaders should be flexible in adapting their leadership styles to the maturity (M) level (both in terms of ability and willingness) of their subordinates and the characteristics of the task. Ability is the knowledge, experience, skills, and abilities demonstrated by an individual or organization in a particular job or activity. Willingness is the confidence, commitment, and motivation of an individual or organization to perform a particular job or activity. This process of employee growth from immaturity to maturity was divided into four stages, named readiness (R) or development (D). The leader’s task behaviors and relationship behaviors comprise the leadership style (S) (shown in Fig. 1). Employees with a high level of maturity may require less guidance and more supportive behaviors, whereas employees with a low level may require more guidance and directive behaviors [5]. Situational Leadership Theory suggests that leaders must be able to differentiate and recognize the current state of the employees if they are to manage effectively.

For leaders, this theory requires leaders to have three skills: diagnosis, flexibility, and agreed-upon leadership styles [7]. Diagnosis refers to assessing the current readiness level of team members; it is the most critical part of situational leadership theory. Flexibility refers to the leader’s ability to apply different leadership styles to different readiness levels of subordinates or to treat the same person with different leadership styles when the situation changes. Agreed-upon leadership style refers to partnering with the person to agree on his or her desired leadership style [8]. In addition, for employees, two dimensions can be used to define the different stages of an employee’s development: work maturity (ability) and psychological maturity (willingness). Work maturity, which includes a person’s knowledge and skills. Subordinates with high work maturity are well educated and trained, have sufficient knowledge and abilities, and are experienced enough to perform their work tasks independently without guidance from others. Psychological maturity refers to a person’s willingness and motivation to do something. Subordinates with high psychological maturity have high self-confidence and are motivated to work. They do not need external incentives but rely mainly on internal motivation [9]. That is, a subordinate’s stage of development is viewed from two perspectives: Ability to work, the relevant knowledge and skills demonstrated by the subordinate when engaged in a particular goal or task; willingness to work, the motivation and confidence of the subordinate when working on a specific goal or task. Accordingly, Hesse and Blanchard categorized the employee growth process into four types (or stages) from low to high [10].

As situational leadership theory continues to evolve and spread, the two founders of the theory have each refined and differentiated the application model of situational leadership theory based on their own perspectives. Paul Hersey [11] registered for Situational Leadership Model, and Ken Blanchard registered for Situational Leadership Model II. With regard to these two situational leadership models, their core advocates a flexible leadership style, whereby leaders should utilize different leadership styles in accordance with the differences in their subordinates’ ability and willingness to perform, as well as the differences in the work tasks and work environments. Whether it is Situational Leadership Model or Situational Leadership Model II, the steps are the same for leaders when utilizing the situational leadership approach. The first step is to define specific work tasks and goals. The second step is to diagnose the ability and willingness of the subordinates in the context of the specific job tasks and goals. The third step is to apply a matching leadership style [10]. Nevertheless, they are different. In Situational Leadership Model, Paul Hersey categorizes it into four different performance readiness according to their ability and willingness, R1-R4 (R1: unable and insecure or unwilling; R2: unable but confident or willing; R3 able but insecure or unwilling; R4: able and confident and willing), S1-S4 (telling, selling, participating, delegating). In Situational Leadership Model II, the Ken Blanchard divides it into four different developmental stages according to their ability and willingness, D1-D4 (D1: low competence, high commitment; D2: low to some competence, low commitment; D3: moderate to high competence, variable commitment; D4: high competence, high commitment), S1-S4 (directing, coaching, supporting, delegating). It is worth noting that the difference between the two models is mainly in the classification of employees, and there is no difference in the connotation of leadership style.

Situational leadership theory has been extensively studied and applied in the context of nursing management for many years. With the continuous development of the medical market and the continuous improvement of the public’s medical needs, the comprehensive quality of the nursing team, especially the head nurse, has been subjected to higher requirements. It is especially important to improve the leadership of nurse leaders and construct effective nursing teams through the use of situational leadership theory [12]. The nurse manager’s leadership behavior directly affects the nurses’ enthusiasm and the improvement of nursing quality [13]. The challenge of building a nursing team with efficient execution to provide patients with high-quality care to meet the demands of modern clinical nursing is a significant problem that every nurse manager must address. Applying situational leadership theory can assist nursing managers in motivating nurses to enhance management efficiency. Studies have shown that nurse managers use different leadership styles to manage nurses based on maturity levels, effectively avoiding resistance from nurses to their managers, inspiring nurses’ work enthusiasm, and improving nurses’ performance appraisals [14]. Zhang et al. [15] report that applying situational leadership theory improved overall clinical quality, including medical document writing quality, accidental injury prevention, medication safety, patient satisfaction, and the quality of clinical teaching. Additionally, the nurse manager is relieved of the burden of overseeing the entire unit and can delegate tasks to highly prepared nurses who are able and willing to assume responsibility [15]. The nurse manager can dedicate more time to managing the work, which improves efficiency and contributes to the quality of nursing care. To practically implement situational leadership theory into the specific work of nurse managers and nurses, managers should assess nurses’ readiness dynamically and use various management techniques to help nurses progress along the R1-R4 or D1-D4 as quickly as possible. That is to facilitate the development of the nursing team [7].

Although situational leadership theory has been widely used in nursing management, the research has many different types of research designs and tools and variations in the methodology used to apply the theory. Therefore, to identify how situational leadership theory has been applied in the field of nursing management, we synthesized the existing literature using a scoping review [16]. To the best of our knowledge, no systematic review of situational leadership theory has been published. In addition, we found that the transparency of the relevant studies was an apparent absence deficiency through our previous review of the studies on situational leadership theory in nursing management. Given that, our objective was to know how situational leadership theory works in nursing management and how the interventions were carried out. Therefore, the transparency of the study plays an important role in the overview of this study and provides some guidance for the referencing as well as reporting of future related studies. In summary, we reviewed studies using reporting guidelines relevant to the study design of the included studies.

This scoping review identifies how situational leadership theory can be utilized in nursing management with respect to theory-related tools, application contexts, roles, and the quality of reporting. The findings highlight the impact of situational leadership theory on nursing management, which theory fully uses the nursing manager’s leadership skills, including the ability to identify and effectively utilize the talents of team members. Situational leadership management is beneficial because of its capacity to optimize leadership effectiveness by adaptively adjusting leadership behaviors based on the growth needs of team members and the complexity of the task [10]. In fact, nursing managers need to exercise effective leadership, which can guide team members to enhance organizational cohesion and core competencies [4]. Consequently, we recommend that situational leadership management be employed to enhance the leadership of managers and the maturity of nurses, thereby further improving the quality and efficiency of care. However, as the included articles report, although empirical research supports the validity of situational leadership theory, the specific application of practice in the nursing field remains inadequate. We found that the SL model and SLII model were not defined in all included studies, that there is a difference between the two theories in distinguishing the levels of employees, and that this difference affects the application of the theories and the implementation of the intervention. We suggest that the SL model or SLII model should be clearly defined in future studies to avoid conceptual confusion and misapplication.

Regarding leadership assessment tools in the situational leadership management model, there are some differences and limitations between the tools. First of all, in terms of assessment criteria, the questionnaire developed by Cardoso [27] used a 6-point Likert scale to assess the knowledge, skills, and attitudes of nurses, while the other tools used situational tests to assess leadership styles. Furthermore, in terms of the content of the assessment, Hersey and Blanchard’s leadership style assessment tool and LEAD were used to determine the type of leadership style, while LBAII and LSSQ were used to examine the flexibility of the leadership style and the effectiveness of the style; in terms of the study population, only Hersey and Blanchard’s leadership style assessment tool and LBAII were used for leaders’ self-evaluation and subordinates’ evaluation of leaders. Although there are multiple well-established situational leadership theory measurement tools, not all studies have validated and reported the reliability and validity of their research tools. Most of the studies from China reported on nurse maturity, but none of them measured nurse maturity using specific measurement tools [15, 25, 26, 34, 35, 39, 40, 42]. This would lead to biases in the assessment results, erroneous findings, and insufficient credibility of the research conclusions. Therefore, scholars need to strengthen the reporting of measurement tools in future research on situational leadership management. In addition, situational leadership theory may have different leadership dynamics in different cultural healthcare settings, and scholars should enhance the development of assessment instruments appropriate for different cultural contexts and utilize modern technological tools to support the practice of situational leadership theory, such as the development of employee maturity assessment systems and leadership development platforms to improve the accuracy of the measurement of leadership styles and maturity in this leadership model [47].

Situational leadership theory is a theoretical perspective suitable for studying team functioning in large inter professional events. In the context of the current complexity of diseases and the growing health needs of patients and families, there is a need to provide comprehensive medical care based on interdisciplinary teams and the full integration of various resources [4]. Leadership is contextual and influenced by situational factors. It suggests that leaders should adjust the degree to which they direct or support their subordinates based on the context [48]. Leaders should adapt their leadership style based on the maturities of their team members and respond to situational demands [49]. Situational leadership requires individuals to be flexible, adapt to the situation, and adopt a leadership style that best suits the needs of their team members to achieve organizational goals, motivate employees, and increase productivity [50]. Leaders can increase employee job satisfaction by using different leadership styles with employees at different maturity levels [51]. It is useful for managers to use situational leadership theory to manage followers. The right management style will enable employees to build on their strengths and complement their weaknesses to improve their work efficiency [10]. Nevertheless, while situational leadership theory emphasizes adjusting leadership styles in response to changes in follower maturity, there may be a degree of continuity and stability in the leadership behavior itself. Leaders need to consider this when adjusting their leadership style and avoid changing it too frequently, which may affect team stability and follower trust [51]. There is also the fact that the implementation of situational leadership theory relies on the leader’s judgment of the employee’s maturity and analysis of the situation. However, these judgments and analyses may be influenced by the leader’s subjective factors, leading to a biased choice of leadership style [28]. Therefore, management should organize leadership theory training and require leaders to participate actively in the training. Participation in training develops flexibility and recognition of leaders’ leadership styles [52]. Encouraging followers to provide feedback to leaders actively will encourage leaders to manage the organization with a more appropriate leadership style, promoting organizational goals [53]. It is worth noting that the review identified major shortcomings in the current reporting of interventions. Specifically, most of the intervention descriptions in the trials are limited in their lack of detail and transparency regarding allocation settings, the timing of the intervention, duration, incentives, and measures taken to reduce potential bias from non-randomization and non-blinding. Moreover, these studies did not provide recommendations for further developing their interventions. This lack of transparency and under-reporting of interventions may be barriers to developing standardized intervention programs [54, 55]. We suggest that future research needs to further improve the reporting of intervention protocols and develop standardized intervention protocols. This will support of the application of situational leadership theory in care management and increase the replicability and quality of research in this area.

Five of the nineteen articles included in this review used observational studies. After a one-by-one check, none of the articles fully met the STROBE review criteria, and a notable deficiency was noted in the methodology. The remaining 13 articles used a non-randomized controlled trial approach, and none of the study designs fully followed the TREND guidelines. These 13 non-randomized controlled trials have deficiencies in the completeness of reporting of methods and results. The TREND reporting guidelines were developed to improve the transparency and accuracy of reporting behavioral and public health evaluations of non-randomized designs [56]. The frequent use of STROBE for reporting observational studies also aims for the same purpose [57]. The early emergence of this type of research and discussion on applying situational leadership theory in nursing management resulted in a low level of transparency and accuracy in the literature in this area.

Situational leadership theory was used in observational studies to assess the leadership of nurse managers. The results of the STROBE statement show that these observational studies have shown a lack of reporting of rigorous study design and funding, with the least reported part of the study design section being the reporting of the study sample size. This means that the representation of these sample sizes to the population was called into question, which could lead to measurement errors in these studies. Consequently, the findings of these observational studies should be referred with caution [27]. At the same time, situational leadership theory explores the relationship between nurse managers’ leadership and the judgments of nurses’ maturity and the match between them. Several quasi-experimental studies have indicated its usefulness in nursing leadership contexts. However, according to a TREND assessment, these studies were found to have poor reporting of study methodology and results. The lack of methodological reporting will similarly affect other scholars’ difficulties to refer to such literature to apply situational leadership to nursing management. Furthermore, it is noteworthy that less than half of the studies reported on the validity of the tools, which puts the reliability of the findings in doubt. In conclusion, the lack of transparency in reporting has resulted in the absence of a referenceable, standardized intervention program and situational leadership theory intervention process in nursing management. Future research may benefit from using STROBE and TREND as a guiding tool to conduct research related to applying situational leadership theory in nursing management. This may increase the transparency and quality of research in this area.

Nurse leadership is essential in the current healthcare environment, and it is key to facilitating nurse professional development and achieving organizational objectives. Situational leadership theory promotes the development of nurse leadership and maturity by identifying and matching nursing managers’ leadership styles and nurses’ maturity to promote improved organizational outcomes. This review provides a comprehensive overview of how situational leadership theory can be used in nursing management, outlining measurement tools, research designs, intervention methods and indicators, and reporting gaps. The extant literature emphasizes the role of situational leadership theory in nursing management. However, some of the applied tools need to be validated, model types and concepts need to be further defined, and the articles report poor transparency, which reduces the credibility of the research and hinders further improvement of the applied methodology. Therefore, in future research, further development of research tools, standardizing application protocols, and adherence of reporting guidelines are strongly recommended.