Nursing Leadership—From Administration to Value‐Informed Leadership

Nursing leadership has evolved substantially over the last five decades in parallel with developments in nursing practice, education, policy, research and technology. These transformations have elevated the role of nurse leaders and significantly influenced patient care and healthcare systems. This commentary describes and reflects on some of the most impactful milestones and developments in nursing leadership over the last 50 years and highlights key issues that nurse leaders will face in the next 50 years. Nursing leadership has undergone significant change since the 1970s, going from a primarily administrative function focused on staffing and operational management to one based on relational leadership styles, evidence-based practice and interprofessional collaboration. This has redefined the role of nurse leaders as strategic influencers of patient care outcomes. Several major studies, programs, and concepts have contributed to this transformation, notably the Magnet Recognition Program, Nursing Sensitive Outcomes, the RN4CAST project, Patient safety culture, Evidence-Based Practice and Crisis Leadership, which will be discussed in the next paragraphs. In 1983, the American Academy of Nursing (AAN) Task Force on Nursing Practice in Hospitals conducted a major milestone survey of 163 hospitals in the US to identify those that were most successful in attracting and retaining nurses while providing high quality patient care. Forty-one so-called ‘magnet’ hospitals stood out in these respects, and the characteristics that distinguished them were referred to as the ‘14 Forces of Magnetism’, a term that is still known today. Building on the 1983 work, the American Nurses Credentialing Center (ANCC) was established in 1990 as a subsidiary non-profit organization through which the American Nurses Association (ANA 2025) offers credentialing programs and services for hospitals. In the same year, the ANA Board of Directors approved the Magnet Hospital Recognition Program for Excellence in Nursing Services (now known as the Magnet Recognition Program) to acknowledge hospitals that achieve nursing excellence. Magnet status was first awarded to a hospital in 1994, and there are currently 642 Magnet hospitals worldwide—619 in the US and 23 in 12 other countries. There are three Magnet hospitals in Europe, with two being in Finland and one in Spain (https://www.nursingworld.org/organizational-programs/magnet/). The Magnet Recognition program has profoundly influenced nursing leadership. Two of the 14 Forces of Magnetism identified in 1983 are quality of nursing leadership and management style, which together form one of the five key components of the modern Magnet model—Transformational Leadership. The model's other four components are Structural Empowerment; Exemplary Professional Practice; New Knowledge, Innovations, & Improvements; and Empirical Outcomes. In general, research on leadership has identified three common leadership styles, namely transactional, laissez-faire, and transformational leadership (Bass 1990; Chen et al. 2024), and the Magnet model recognises the value of transformational leadership in nursing. The important role of the Chief Nursing Officer has been highlighted since the beginning of the program; the Magnet model states that nurse leaders are knowledgeable, visible, humane, accessible, flexible, supportive, good listeners and visionary leaders. A transformational leader advocates for and supports staff to ensure high quality and safe care for patients at all levels, which is always the main goal of nursing and nursing leadership (Nurmeksela et al. 2025). It should be noted that although the Magnet model has played an important role in making nurse leaders' work visible, it is not clear how well it describes the situation in current healthcare globally. There is a large body of research on Magnet hospitals, much of which has been conducted in the US and published in the Journal of Nursing Administration, the Official Leadership Journal of the Magnet Recognition Program, which was introduced in 1971, age-mate to the Journal of Advanced Nursing. The Magnet model has since drawn global interest, even in institutions not seeking Magnet status, and there have been many important developments based on the model, which features nursing leadership as a core topic. In recent decades, nurse leaders have worked to shift the direction of nursing development towards transformational leadership. However, the challenge of implementing this approach at all levels of the healthcare organization remains. The concept of Nursing Sensitive Outcomes (NSOs) has become a cornerstone of nursing care quality assessment in recent decades. The Donabedian Model (Donabedian 1988) has been used a lot to conceptualise and evaluate quality in terms of structure, process, and outcomes. This model is linear: it assumes that structure influences processes and thus affects outcomes. NSOs are patient outcomes such as the incidence of pressure ulcers, falls, infections, and patient satisfaction, as well as nurse outcomes such as job satisfaction, turnover, and burnout rates. They have become essential tools for assessing nursing performance and guiding quality improvement initiatives in healthcare systems worldwide (Oner et al. 2021). The establishment of the National Database of Nursing Quality Indicators (NDNQI) in 1998 by the American Nurses Association marked a pivotal moment in standardising NSOs across healthcare institutions because it enabled systematic tracking of nursing-sensitive indicators and demonstrated the economic and clinical value of nursing care (Dunton 2008). The principle of systematically collecting nursing-sensitive quality indicator data has been adopted globally, making it increasingly important for nurse leaders to monitor and analyse such data in order to effectively lead the implementation of changes in practice. In a systematic literature review entitled ‘Leadership styles and outcome patterns for the nursing workforce and work environment’, Cummings et al. (2010) examined 53 studies published between 1985 and 2009: 32 from North America, 15 from Europe, one from Australasia, and five from non-specific countries. The main finding was that relational leadership styles (especially transformational leadership) were associated with higher job satisfaction among nurses. A recent systematic review of reviews (Hult et al. 2023) similarly concluded that relational leadership styles, particularly transformational leadership, are positively associated with improvements in NSOs including the incidence of adverse events, nurse performance, and patient satisfaction. Conversely, passive or autocratic leadership styles correlated with lower staff engagement and poorer outcomes. Despite these advances, challenges remain. Leadership gaps, burnout, and staffing shortages reduce nurse leaders' ability to sustain high-quality care, which is important because the interplay between nursing leadership and NSOs has become stronger over the past decades. Strengthening leadership competencies and embedding NSOs into organisational culture are thus essential for achieving safe, efficient, and patient-centered care. Future research should continue examining innovative leadership models and their long-term impact on nursing-sensitive indicators. The EU-funded RN4CAST project, which ran from 2009 to 2011, was the one remarkable milestone and one of the largest workforce studies ever conducted in Europe, bringing together researchers from twelve European countries (Belgium, Finland, Germany, Greece, Ireland, Norway, Poland, Spain, Sweden, Switzerland, The Netherlands and England), the US, Botswana, China and South Africa. The project continued the unique and outstanding health workforce research of Professor Linda Aiken, University of Pennsylvania, US (Aiken et al. 2001). RN4CAST aimed to improve the accuracy of forecasting models and generate new approaches for more effective management of nursing resources in Europe (Sermeus et al. 2011). To this end, it investigated how nursing workforce dynamics (e.g., numbers of nursing staff, skill mixes, and the working environment) affected nurse wellbeing and patient outcomes. Its findings showed that hospital quality, safety and staff retention problems were common to all countries and were associated with differences in the organization of nursing care between hospitals. One of its most important findings is that almost every studied country had one or more hospitals that nurses ranked as having good work environments. Additionally, nurses' and patients' assessments of which hospitals provided good care consistently aligned well (Bruyneel et al. 2015). These findings can be seen linked to the results of studies on Magnet hospitals. The RN4CAST project has profoundly influenced nursing leadership by providing robust empirical evidence linking nurse staffing levels, educational qualifications, and working environments to patient outcomes such as safety, satisfaction and mortality. For example, nurse leaders and workforce researchers even now commonly refer to the project's results. Importantly, RN4CAST has empowered nurse leaders to embrace strategic workforce planning that goes beyond traditional headcount metrics by incorporating quality indicators and predictive modelling (Sermeus et al. 2011). The project also emphasised the importance of transformational leadership, showing that supportive and participatory leadership enhances nurse satisfaction and retention, which in turn improves patient care. RN4CAST has strengthened nurse leaders' roles in healthcare systems by highlighting their critical contribution to organisational performance and patient safety. Patient safety has traditionally been one of the core values related to the quality of care in healthcare. One meaningful milestone of patient safety was the report of the Institute of Medicine: To Err Is Human: Building a Safer Health System (Institute of Medicine 2000), which has strongly influenced the development of patient safety around the world, greatly increasing the attention it received in practice, research and leadership. A key finding of the report is that patient safety is closely related to nursing sensitive outcomes such as the incidence of pressure ulcers, hospital-acquired infections, and falls. Nurse leaders, and especially nurse managers, play vital roles in creating and sustaining a safety culture in areas they oversee by encouraging staff to participate in analyses and open discussions of patient safety incidents. However, it takes time to learn to discuss patient safety problems frankly. Powerful leaders are needed at all healthcare levels (including ministries, healthcare facilities, and every clinical team) to sustain and develop patient safety culture. While much work along these lines has already been done, there is an ongoing need for new patient safety leaders with the passion to strengthen patient safety culture by creating conditions and organisational and team cultures that promote safer care, ensuring that systems and procedures satisfy the highest standards, and working to involve, guide, and motivate staff in patient safety work (WHO 2021). The 1990s and 2000s saw a shift from tradition-based towards evidence-based practice. Evidence-based practice (EBP) and nursing leadership are interdependent pillars that support quality, safety and innovation. While EBP ensures that clinical decisions are grounded in the best available research and expertise, nursing leadership provides the vision, support, and strategic direction to implement and sustain these practices across healthcare systems. Nurse leaders are essential for translating evidence into practice. They create the conditions for EBP to thrive by fostering a culture of inquiry and continuous improvement, providing resources and training that enable nurses to access and apply research findings, encouraging interdisciplinary collaboration to support holistic care, and advocating for policy changes that align with evidence-based standards. Effective nurse leaders have been seen as change agents, guiding teams through the adoption of new practices and ensuring that care delivery is both scientifically sound and patient-centered. According to the previous research, evidence-based leadership interventions can improve nursing sensitive outcomes at patient care, nursing workforce and organisational levels (Välimäki et al. 2024). Unfortunately, there is a lack of information about how much nurse leaders use evidence in their leadership roles or the impact of evidence-based leadership in nursing (Välimäki et al. 2024). More knowledge and a deeper understanding of the role of nurse leaders and how they can use evidence in their own leadership decisions is thus needed. Evidence-based practice (EBP) improves patient outcomes and reduces healthcare costs (Connor et al. 2023). Given the clear evidence of its positive impacts, nurse leaders and managers should support and implement EBP. However, research has shown that although nurse leaders acknowledge the value of EBP, they often fail to implement it. Partly for this reason, it currently takes around 15 years (with a range of 13–21 years) for research evidence to be implemented in real-world clinical settings (Melnyk 2023). This raises a simple question: why? The COVID-19 pandemic was a pivotal moment in the evolution of nursing practice and leadership, leaving a lasting imprint on the professional consciousness. Nursing leadership during the pandemic required resilience, relational competence, and strategic foresight. As frontline coordinators and decision-makers, nurse leaders were required to navigate uncertainty while maintaining the quality and safety of care delivery. The crisis leadership literature emphasises the importance of several core competencies including decision-making skills, adaptability, emotional intelligence, and trust-building, as well as effective and timely communication. The COVID-19 pandemic highlighted the critical importance of these competencies in nursing leadership (Kim 2021; Al Sabei et al. 2022; Sihvola et al. 2022). Studies have shown that the pandemic challenged and transformed the daily work of healthcare leaders and nursing staff in multiple ways (Ahlqvist et al. 2023). It required leaders to display strong visibility and leadership, which in turn reinforced nurses' resilience (Sihvola et al. 2022). High levels of resilience among nurses were found to positively impact both the quality of care and job satisfaction during the pandemic (Sihvola et al. 2023). These insights are critical for preparing nurse leaders for future global health emergencies. There is an expectation that the future healthcare systems will be increasingly complex, so nursing leadership will face multifaceted, old and new, challenges and opportunities over the next 50 years that demand novel solutions, innovation, resilience, and a strategic perspective. Although the future is unclear, we have to be confident that nursing leadership will continue to evolve and the future will be better than the past. Next paragraphs will discuss the key issues, which nurse leaders will meet in future include workforce shortages, becoming active in policy and advocacy, Artificial Intelligence, climate change and global health emergencies, social determinants of health, financial resources, and finally the value-informed nursing leadership. Ongoing nursing workforce shortages pose a significant threat to global health systems (WHO 2025a). This challenge is multifaceted, caused by an aging workforce and populations, increasing need for care, and limited capacity in nursing education programs. According to the WHO (2025a), strategic investment in nursing education, employment, leadership, and service delivery is urgently needed to address these deficits. Workforce shortages have severe adverse effects on patient safety, care continuity, and system resilience. To react to this, nurse leaders' key responsibility is to adopt robust and sustainable recruitment and retention strategies from a global nursing perspective, take responsibility for fostering mentorship, and advocate for improved staffing ratios and healthier work environments. Leadership that prioritises workforce sustainability is essential to ensure a sufficient nursing workforce in the future together with quality of nursing care. Nurse leaders will have an increasingly transformative role in shaping health policy and advocacy in the future. Nurses are the largest occupational group in healthcare and are essential to achieving universal health coverage and the Sustainable Development Goals (SDGs) (WHO 2025a). However, despite their numbers and frontline expertise, nurses remain underrepresented in policymaking and executive leadership. The WHO highlights the impact of nursing education, leadership development, and workforce planning to empower nurses to act as policy influencers (WHO 2025a). The number of Government Chief Nursing Officer positions has increased significantly in recent years, but many countries still lack them, including some in Europe (Smith et al. 2025; WHO 2025a). Regardless, every country should have a senior nurse leader at the government level who serves as a national nursing policy maker. The existence of such a position does not solve anything in and of itself, but it ensures that nurse leaders have an official presence at the table when decisions are made; they must seize the opportunity to use their voices. Policy training, mentorship and organisational support to prepare nurses for leadership in governance and advocacy roles will thus be essential (Stewart et al. 2025). Artificial intelligence (AI) is expected to be increasingly important in transforming leadership roles. 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