Background
European hospitals are facing multiple challenges, including economic pressure, cost containment strategies, technological advancements, and shortages of healthcare professionals, which require constant adaptation [
1‐
4]. Particularly concerning is the high burden of mental distress reported by nurses and other healthcare professionals [
5,
6]. It is increasingly recognized that the root causes of increased stress and burnout among nurses are linked to the work environment in hospitals and other healthcare settings, that is why hospitals should strive to change their working conditions [
7,
8].
The Magnet Recognition Program® (Magnet) and the Pathway to Excellence® Program (Pathway), both originating in the United States (U.S.) and held at the American Nurses Credentialing Center (ANCC), are designed to facilitate organizational-wide change of work environments, enhancing employee well-being, retention, productivity, and patient outcomes [
9‐
11]. These concepts can provide a structured approach for European hospitals to tackle the challenges of the future effectively.
Research on Magnet hospitals, primarily conducted in the U.S., suggests that Magnet can enhance working conditions, job satisfaction, and nurse well-being in hospitals [
12‐
15], while also improving patient outcomes [
14‐
16]. However, findings across studies and outcomes vary. In contrast, the impact of Pathway has received less attention in research. Nevertheless, some studies have indicated that Pathway promotes increased nurse autonomy and decision-making authority, fosters leadership development, improves safety and quality standards, enhances employee well-being, and supports professional growth [
17,
18].
As of December 2023, 591 organizations worldwide had Magnet designation [
19], and 214 had Pathway designation [
20], with the majority in the U.S. Internationally, only 17 hospitals hold Magnet designation [
19] and 16 have Pathway designation [
20]. While none of them are in Germany, some German hospitals have proactively started implementing Magnet/Pathway principles to drive organization-wide changes aiming at enhancing job satisfaction, attracting and retaining healthcare professionals [
21‐
24]. Hence, the inclusion of Magnet and Pathway principles as comparable case examples of organization-wide change in the current study is justified by the growing proactive adoption of these concepts by some German hospitals.
Magnet and Pathway focus on promoting nurse engagement and supporting professional nursing practice environments. The difference lies in their specific objectives: Magnet emphasizes sustained quality patient care, nursing excellence, and innovations in professional practice, while Pathway highlights creating supportive practice environments that empower and engage staff and is known for having less stringent data requirements [
25,
26]. However, both aim to cultivate a culture of nursing care excellence, supported by a transformational leadership style [
25], which is the central focus of the present study.
Leadership skills do play a crucial role in successfully promoting organization-wide change [
27‐
29] and has also been shown to have a profound impact on employee stress and emotional well-being [
30]. Transformational leadership was identified as one effective leadership style in healthcare settings [
29,
31‐
33]. Transformational leaders motivate employees towards an organizational vision by inspiring and empowering them to continuously develop themselves and addressing their individual needs [
34,
35]. The theoretical framework for transformational leadership was first conceptualized in the 1970s, defining it as a relationship between leaders and employees who motivate, empower, and elevate each other’s moral values in pursuit of fulfilling common interests [
36]. Further expansion by Bass and Avolio introduced four subcategories that represent the characteristics of transformational leaders: Idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration [
34,
35].
Several U.S. studies have analyzed the relationship between transformational leadership and the implementation of Magnet principles [
37‐
39]. In a southern U.S. nonprofit acute care hospital seeking Magnet designation, a survey of 115 staff nurses showed that transformational leadership style was positively associated with nurses’ job satisfaction and satisfaction with promotion opportunities [
37]. Magnet hospital CNOs rated their transformational leadership practices highly and reported a strong positive correlation between engagement and leadership practice, with empowering others as the most important practice [
38]. A study of clinical nurse leaders, who attended the 2016 Magnet Conference in Orlando, Florida, showed a positive relationship between transformational leadership practices and work engagement, but observed differences in leadership practices and work engagement based on varying levels of education [
39].
The majority of research conducted outside of the U.S. has focused on investigating the impact of transformational leadership style within healthcare settings, with no focus on the implementation of Magnet/Pathway [
29,
31‐
33,
37,
40‐
45]. Several studies found that forms of transformational leadership styles resulted in positive organizational performance, such as improved staff retention, lower turnover, and better quality of care [
31‐
33,
37,
40,
41]. A systematic review including 12 studies from the US, Canada, Saudi Arabia, China, Ethiopia, Italy, and Jordan, showed a positive correlation between transformational leadership and nurses’ job satisfaction in the hospital setting [
29].
To date, most of the qualitative studies analyzed transformational leadership style from the nurse leaders’ perspective. A study from Finland used a qualitative design to examine nurses’ leadership skills in leading change [
44]. They identified three main roles: First, ‘leading interpersonal relationships’ including competencies of being a team player, coach, and parental figure. Second, ‘leading processes’ including competencies such as organizing, coordinating, and being a conductor based on the organization’s mission. And third, ‘leading a culture’ is defined as advocating values and norms and creating an open, resilient, and evidence-based culture [ibid.]. Another study from 2016 explored senior nurses’ experiences of organization-wide change leadership in three NHS acute hospitals in England through in-depth interviews [
43]. The aspect of leadership was frequently discussed in relation to organization-wide change. An effective nurse leader was characterized as a strong, inspiring, and supportive leader with novel and heroic approaches [ibid.]. Weak leaders were those who did not encourage their teams, had poor presence and were unresponsive to the need for change [ibid]. Another qualitative study used a grounded theory approach to examine the processes nursing management uses to promote change on their wards in five hospitals in Japan [
45]. According to the interviewees, the change management process led by nurse managers consists of having beliefs and being able to empathize with the nursing staff to achieve common goals [ibid.]. Four characteristics of nurse leaders were reported as indispensable factors for change: having both a micro and macro perspective; respecting their own beliefs and external standards; being proactive; having empathy for nursing staff [ibid.]. A 2020 study conducted in a university hospital in Brazil, examined the challenges of exercising transformational leadership and strategies nurses leaders used to address these challenges include being role models for the team, proactively maintaining dialogue with co-workers, and building empathetic relationships [
42].
In German hospitals, a cross-sectional study investigated nursing leadership styles, analyzing the self-assessment of 93 ward managers and the external evaluation of 1,567 employees with the multifactorial leadership questionnaire (MLQ-5X), revealing the presence of transformational leadership practices [
46]. The ward management consistently achieved mean values above the scale mean in all dimensions of transformational leadership, both in the self-assessment and in the external evaluation [ibid.]. However, despite the acknowledged existence of transformational leadership practices in nursing within German hospitals, research on the attributes of nurse leaders that support organization-wide change through implementation of Magnet/Pathway principles remains scarce. This study aims to identify beneficial attributes of nurse leaders from German hospitals, shedding light on their role in driving organization-wide change through Magnet/Pathway and advancing the understanding of leadership practices’ impact within the German healthcare systems. Research on this topic is critical to fill a gap in the literature regarding nurse leader attributes that facilitate organization-wide change and can provides insights that could inform nursing leadership development initiatives tailored to the needs of German hospitals seeking Magnet/Pathway designation.
Discussion
The findings of this study shed light on the attributes of nurse leaders in German hospitals that drive organization-wide change using Magnet/Pathway, which are aimed at improving employee well-being, productivity, and patient outcomes. A key component of the concepts is the practice of transformational leadership [
9]. The results highlight five main themes that encompass beneficial leadership attributes: visionary, strategic, supportive, stamina, and agility.
The theme of visionary underscores the significance of visionary leadership in driving organization-wide change towards Magnet/Pathway. Having a clear and compelling vision that is communicated effectively to employees emerged as a key factor. The role of leaders as role models who embody vision and values was also emphasized. This aligns with existing literature on transformational leadership, which emphasizes the importance of idealized influence and inspirational motivation [
34,
35]. Leaders who serve as role models and inspire others create a sense of identification and motivation among employees to work towards common goals.
The theme of strategic highlights the role of strategic planning and resource allocation in Magnet/Pathway implementation. Several studies confirmed that strategic thinkers are among the most effective leaders. People with the ability to think strategically are more likely to ensure the sustainable success of an organization and are better able to put existing strategic plans into execution [
50‐
53]. Furthermore, this study emphasizes the importance of leaders advocating for Magnet/Pathway principles to gain the support and commitment of the top management. Convincing the top management was seen as crucial for the success of change efforts.
The supportive theme emphasizes the significance of individualized support for employees’ development and well-being. This includes empowering employees to pursue further education, addressing their unique needs, and fostering a trusting work environment. This study highlights the role of leaders in providing resources and support for academic advancement, which aligns with the Magnet key component on structural empowerment. Furthermore, the importance of team spirit and collaboration was emphasized, echoing the Magnet/Pathway principle of exemplary professional practice and a collaborative work environment. Supportive leaders act as team players and inspire and motivate their staff to perform beyond the norm [
38,
54]. They support staff nurses to assessing their own performance, working out their goals and defining their responsibilities [
38,
43,
44]. As a result, nurse leaders can promote knowledge building, intrinsic motivation and innovative work behavior among nurses [
54].
In the German healthcare system, it is noteworthy that not every nursing director automatically holds a position on the hospital’s executive board, underscoring the importance of engaging top management in organizational change initiatives. Additionally, given that lifelong learning and continuous professional development are not standard practices in nursing in Germany, contrasting with the conditions required for Magnet/Pathway implementation, it highlights the crucial role of CNOs in empowering their staff and fostering a culture of lifelong learning and professional growth.
Results of previous qualitative studies analyzing transformational leadership style from the nurse leaders’ perspective confirm these findings. They include competencies such as a strong, inspiring, and supportive leader with novel approaches. The leaders serve as role models and are able to empathize with nursing staff to achieve common goals [
42‐
45]. By cultivating a visionary outlook and a supportive stance, nurse leaders can effectively foster work engagement, address burnout, and create a motivating environment for healthcare professionals. Importantly, these leadership qualities can be learned and improved over time among nurses through targeted educational interventions, training, mentoring, and hands-on experiences [
55‐
57]. Nevertheless, while some leadership skills can be developed through training and experience, certain innate character traits may provide an inherent advantage in the cultivation of effective leadership [
58]. For instance, personality traits such as emotional intelligence, empathy, and authenticity have been linked to leadership effectiveness [ibid.]. Although these traits may not be directly teachable, they may serve as foundational elements that contribute to the development of successful transformational leadership practices.
The alignment between the findings of this study and those from various international contexts raises important implications for both the Magnet/Pathway implementation process and the broader understanding of transformational leadership. The resemblance between the identified leadership attributes and those found in studies conducted in different countries suggests a level of universality in the leadership qualities required for successful organization-wide change, particularly in healthcare settings. Furthermore, the consensus between the leadership attributes identified in this study and those from international research may imply that studies solely focused on transformational leadership can offer relevant insights for organizations pursuing Magnet/Pathway designation.
Given the diversity of leadership approaches across other sectors (including industry), it is important to recognize the contextual relativity of specific leadership traits. While the leadership attributes identified in this study are tailored specifically to nursing within hospitals, they may be relevant in other sectors, but require further evaluations in different contexts. While a leader’s ability to communicate a clear vision and motivate employees is as crucial in the business sector as in healthcare, the best way of communication and motivation may vary.
New insights that expand the understanding of the role of leadership in driving organization-wide change that emerge from this study is the perspective on the themes of stamina and agility in the context of transformational leadership and Magnet/Pathway implementation.
The theme of stamina reflects the perseverance and resilience required for implementing Magnet/Pathway principles. Leaders need courage to navigate uncertainty and take calculated risks. Leaders should want to make changes and push them forward with stamina and assertiveness, and who are not afraid to speak up and ask for support from higher authorities. In the context of transformational leadership, stamina has often been discussed as a leader’s perseverance, determination, and resilience in the face of challenges [
34]. However, the findings of this study emphasize a more profound dimension of stamina as the leader’s ability not only to persevere, but also to inspire and sustain momentum during complex, long-term endeavors such as Magnet/Pathway implementation.
The concept of agility as an essential leadership skill has gained attention in recent years and refers to a leader’s ability to adapt quickly to changing circumstances. This aligns with the dynamic nature of healthcare settings, where leaders must respond to changing demands [
59]. Interviewees in this study emphasized the positive impact of agile leadership, which enables leaders to respond rapidly, purposefully, and individually to different situations [
59‐
61]. By adapting task structures and difficulty levels to match employees’ needs and commitment, leaders can prevent both under- and over-challenging their team members, thereby facilitating their professional development [
59‐
61]. With the sub-themes showing presence as well as accessibility and responsiveness, it became clear that leaders should be in regular exchange with their employees to be able to react agilely to the requirements and needs [
62]. In contrast, the findings confirm that the lack of frontline presence as well as the leader’s lack of interest in the processes negatively impacted the success of Magnet/Pathway implementation. However, in the context of Magnet/Pathway implementation, agility goes beyond flexibility to include a dynamic responsiveness to evolving healthcare challenges. The results show that leaders need to be flexible not only in their decision-making, but also in their accessibility and responsiveness to employees. This reflects a proactive approach that not only supports the implementation of the Magnet/Pathway principles, but also ensures that employees remain engaged and motivated throughout the transformation process.
Limitations
This study has several limitations. Firstly, the interviews were conducted in only five German hospitals, yet they were the first ones known to have started introducing Magnet or Pathway in Germany. While these hospitals provided valuable insights into the implementation process, the perspectives shared by leaders and staff are not representative of all hospitals in Germany, limiting the generalizability of the findings. Secondly, the majority of interviewees in this study were nurse managers or individuals with leadership responsibilities. As a result, the findings primarily reflect the management and leadership perspective, potentially overlooking the viewpoints and experiences of frontline nurses. It is important to consider a wider range of perspectives to gain a comprehensive understanding of the challenges and opportunities associated with leadership while implementing Magnet/Pathway principles.
Conclusions
This study provides in-depth insights into the leadership attributes that drives the implementation of organization-wide change through Magnet/Pathway principles in German. It offers guidance for nurse leaders seeking to drive positive organization-wide change and enhance employee well-being.
The interviewees in this study emphasized the importance of leadership competencies such as visionary direction, strategic planning, personalized support, resolute stamina, and adaptive agility. The themes of stamina and agility offer new insights, showcasing the need for courage, assertiveness, and adaptability in leaders driving long-term organization-wide change towards Magnet/Pathway.
Given the vital role of transformational leadership in driving organization-wide change, as well as the fact that transformational leadership skills can be trained, a comprehensive preparation and ongoing development of nurse leaders toward transformational leadership skills may support establishing and sustaining a positive work environment in hospitals.
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