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Analysis on the current situation and influencing factors of clinical leadership of* Correspondence: Yuan Chen 28837445@qq.com
cardiovascular nurses in China, a cross-sectional study
Ligang Wang1, Haiyan Yu1, Linjing Wu1, Wu Xianfeng1 and Yuan Chen1༊
1 Department of Nursing, Xiamen Cardiovascular Hospital, Xiamen University, No. 2999, Jinshan Road, Huli District, Xiamen, 3610000, China.
Abstract
Background
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Clinical leadership is a crucial competency for cardiovascular nurses, as it directly influences the quality of cardiovascular care, interdisciplinary collaboration, and patient safety outcomes within the high-intensity, complex clinical environment of cardiovascular diseases. Understanding the current status and influencing factors of clinical leadership among cardiovascular nurses is critical for developing targeted interventions to enhance their professional capabilities and improve cardiovascular care. Therefore, the purpose of this study was to investigate the status quo of the clinical leadership among cardiovascular nurses, analyze its influencing factors, and provide a reference for formulating improvement strategies.Methods
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The study was conducted with a sample of 411 cardiovascular nurses from a tertiary hospital in Xiamen, selected using a convenience sampling method between January and July 2025. The tools used included a general information questionnaire, the Clinical Leadership Scale, the Nursing Work Environment Scale, and the General Self-efficacy ScaleResults
The total score of clinical leadership of the 411 cardiovascular nurses was (63.53 ± 9.81), with an average item score of (4.24 ± 0.82), indicating an above-average level. Multivariate linear regression analysis identified the title, department, and whether underwent training on clinical leadership, the nursing work environment, and the general self-efficacy (all P < 0.05) as the influencing factors for the clinical leadership of cardiovascular nurses.
Conclusion
It is recommended that nursing managers offer targeted interventions based on the influencing factors to improve the clinical leadership of cardiovascular nurses, which requires targeted interventions, including expanding training opportunities, optimizing the nursing work environment, and strengthening self-efficacy development. These measures are essential to improve the quality of cardiovascular nursing care and patient safety outcomes.
Keywords
Cardiovascular
Nurse
Clinical leadership
Influencing factor
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Introduction
With social and economic development, the global aging population and accelerating urbanization, unhealthy lifestyles are becoming increasingly prevalent, and the impact of cardiovascular diseases (CVD) on public health is growing more significant [1]. CVD caused approximately 19.8 million deaths globally in 2022, generating 396 million disability-adjusted life-years lost. CVD deaths are the leading cause of death among urban and rural residents [2]. China is currently facing a growing challenge from CVD, which have become increasingly prevalent across the country, conditions such as hypertension, coronary heart disease, and stroke are placing an immense burden on the healthcare system and the lives of affected individuals [3]. Given the high morbidity and mortality rates linked to CVD, delivering high-quality nursing care is critically important. Cardiovascular nurses play a vital role across the entire spectrum of care—from prevention and early diagnosis through treatment and post-discharge rehabilitation.
Clinical leadership is an ambiguous and context-dependent concept. A growing body of literature has recently attempted to clarify this relatively new concept, however, its meaning is still unclear [4], especially in the hospital context, nurses’ clinical leadership refers to nurses who are directly involved in providing nursing care at the bedside and who exert influence on health care team colleagues to achieve positive patient outcomes, even though no formal authority has been vested in them [5], which is regarded as one of the important core competencies of clinical nurses and plays an important role in improving the overall quality of nursing and promoting nursing team collaboration [6]. The leadership not only affects the professional level of nurses, but also directly relates to the quality of care and nursing management effectiveness of patients [7]. Nurses' clinical leadership plays an important role in ensuring patient safety [8], improving patient satisfaction, and promoting quality nursing care.
According to the International Council of Nurses (ICN), launched in 1995, the ICN Leadership for Change (LFC) program aims to equip nurses with the leadership skills necessary to implement organizational change, improve nursing practice, and achieve better health outcomes [9]. The World Health Organization (WHO) stated in its Global Strategic Directions for Nursing and Midwifery 2021–2025 that enhancing nursing leadership will be one of its key strategic priorities. Despite the crucial role nurses play in cardiovascular care, there is a scarcity of research examining the clinical leadership of cardiovascular nurses. Understanding the current status and the factors influencing their clinical leadership is essential. Therefore, the purpose of this study was to explore the current status of clinical leadership among cardiovascular nurses, as well as analyze the relevant factors influencing nurses’ clinical leadership so as to provide a theoretical basis for nursing managers to develop strategies for enhancing their clinical leadership.
Methods
Study design
The study used a cross-sectional survey. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [10] (Appendix S1) was chosen as a checklist for this study.
Study participants
A convenience sampling method was used to conduct a questionnaire survey on
cardiovascular nurses from a large public tertiary cardiovascular specialty hospital in
Xiamen, Fujian Province, China. Cardiovascular nurses were selected for this study between January 2025 and June 2025. The inclusion criteria for nurses were as follows: (1) nurses who held a nursing qualification certificate; (2) nurses who working in the cardiovascular field for at least one year; and (3) nurses who voluntarily participated in this study. The exclusion criteria were: (1) nurses who are not on duty due to vacation or external training during the data collection period; nurses from other hospitals who come to our hospital for further study; and (2) nurses undergoing practical training.
Based on the sample size estimation method for Kendall correlations [11], the sample size was estimated to be at least 5 to 10 times the number of observed variables. To account for potential sample loss and invalid cases, a 10% attrition rate was added. Given that the study included 60 variables, the required sample size for the calculation is 310 cases.
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The study was reviewed and approved by the Ethics Committee of Xiamen Cardiovascular Hospital, Xiamen University, Informed consent was obtained from all the cardiovascular nurses.Measures
Four instruments were used in this study. The use of the questionnaire has been authorized by the author or the translator.
Study Tools
Demographics and work characteristics
Demographics and work characteristics were designed by the researcher, cardiovascular nurses who participated in this study were asked to provide information about their gender, age, title, educational qualifications, department, and whether underwent training on clinical leadership, etc.
Clinical leadership scale
The Clinical Leadership Scale, developed by Canadian scholar Patrick [12], was translated and adapted into Chinese [13]. It consists of 5 dimensions: challenging the current situation (3 items), inspiring the vision (3 items), set an example (3 items), inspiring others (3 items), and motivating people (3 items), with a total of 15 items. The questionnaire was scored on a positive five-point Likert scale, with scores ranging from 1 to 5 for “almost never” to “almost always”. Higher the score, the better the ability to implement behavior and the stronger the clinical leadership of cardiovascular nurses. The Cronbach's ɑ coefficient of the questionnaire was 0.945, indicating acceptable reliability of the scale.
Nursing work environment scale
The Nursing Work Environment Scale was developed by Jing Shao in 2016 [14]. It consists of 7dimensions: medical relationship (4 items), leadership and management (4items), basic guarantee (3 items), career development (5 items), professional autonomy (4 items), recognition atmosphere (3 items), and sufficient manpower (3 items), with a total of 26 items. The questionnaire was scored on a positive six-point Likert scale, the total score ranges from 26 to 156 points, with higher scores indicating better nursing work environment. The Cronbach's ɑ coefficient of the questionnaire was 0.964, indicating acceptable reliability.
General self-efficacy scale
The General Self-efficacy Scale was originally developed in Chinese by Kaikang Wang et al [15], with a total of 10 items, to measure the self-efficacy level of participants. All options of this questionnaire were scored on a positive four-point Likert scale, with scores ranging from 1 to 4 for “completely incorrect” to “completely correct”. The higher the score, the better the individual's self-efficacy level. The Cronbach's ɑ coefficient of the entire questionnaire was 0.965.
Method of data collection
Randomly select 30 nurses engaged in the cardiovascular field for a presurvey, all of whom indicate that the items are understandable. The questionnaire survey was performed using an online survey tool Questionnaire Star (Ranxing, Changsha, China) and the link to access the survey was distributed by the social software WeChat (Tencent, Shenzhen, China), which was approved by the director of nursing department of hospital and sent to the head nurse before the survey. The head nurse sent the questionnaire link, research purpose and criteria of included subects to the department’s Wechat group, and nurses filled the questionnaire voluntarily.
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A unified guideline was set at the beginning of the questionnaire to inform the survey purpose, filling method and notes for filling in the questionnaire. All nurses filled in the questionnaire anonymously and independently. To avoid repeated filling, the questionnaire can be filled only once from the same account and device. In order to ensure the complete collection of questionnaires, each question was set as a mandatory field.Statistical analysis
SPSS26.0 was used for data interpretation and statistical analysis. Counting data such as title and gender were described by frequency and component ratio. After the normality test, the data were normally distributed, so the measurement data, such as age and working years, were described by means and standard deviations (SD), and the correlation between variables was tested by Pearson correlation analysis. Comparisons between groups were done using analysis of variance (ANOVA) and independent samples t-test with pairwise comparisons was conducted using the SNK-q test. Multiple linear regression analysis was used to examine related factors, and P < 0.05 was considered statistically significant.
Results
General information of cardiovascular nurses
411 young cardiovascular nurses were finally included, of whom 65 (15.82%) were male, and 346 (84.18%) were female. The age of cardiovascular nurses concentrated at 30ཞ40 years old, accounting for 47.45%. The title of senior nurse was accounting for 47.45%. There were statistically significant differences in the clinical leadership scale scores of nurses working in the cardiovascular field based on their gender, professional title, department, and whether they had undergone training on clinical leadership (P < 0.05) (Table 1).
Correlation analysis of clinical leadership, nursing work environment and self-efficacy among cardiovascular nurses
The results showed that the total scores of the clinical leadership, nursing work environment, and self-efficacy were 63.53 ± 9.81, 156.58 ± 23.47, and 32.60 ± 5.59, the score of each scale is shown in Table 2. Pearson correlation analysis showed that work environment, and self-efficacy were positively correlated with clinical leadership scores, as shown in Table 3.
Multiple linear regression analysis on factors influencing clinical leadership among cardiovascular nurses
Multivariable linear regression analysis was performed with the total score of
the clinical leadership among cardiovascular nurses as the dependent variable, the items with P < 0.05 as the independent variable. The analysis showed the gender, title, department, and whether underwent training on clinical leadership, the nursing work environment, and the general self-efficacy were positive influencing factors of clinical leadership, as shown in Table 4.
 | ||||
|---|---|---|---|---|
Items | Number of cases(%) | score | F/t value | P value |
Gender | ||||
Male | 65(15.82) | 61.14 ± 10.93 | t=-2.147# | 0.032 |
Female | 346(84.18) | 63.97 ± 9.54 | ||
Age group(years) | ||||
20ཞ29 | 156(37.96) | 62.91 ± 9.46 | F = 1.769* | 0.172 |
30ཞ40 | 195(47.45) | 63.36 ± 10.16 | ||
≥ 41 | 60(14.6) | 65.67 ± 9.44 | ||
Title | ||||
Nurse | 33(8.03) | 64.45 ± 10.63 | F = 4.226* | 0.015 |
Senior nurse | 195(47.45) | 62.06 ± 9.21 | ||
Supervisory Nurse and above | 183(44.53) | 64.92 ± 10.12 | ||
Duration of overall work experience(years) | ||||
1ཞ5 | 108(26.28) | 63.29 ± 9.87 | F = 2.367* | 0.07 |
6ཞ10 | 157(38.2) | 62.2 ± 10.20 | ||
11ཞ15 | 59(14.36) | 65.56 ± 8.81 | ||
≥ 16 | 87(21.27) | 64.84 ± 9.45 | ||
Department | ||||
Internal Medicine | 164(39.9) | 64.17 ± 9.77 | F = 2.362* | 0.03 |
Surgery | 50(12.17) | 63.06 ± 9.07 | ||
Pediatrics | 4(0.97) | 62.00 ± 3.37 | ||
Intensive Care Unit | 76(18.49) | 60.99 ± 9.76 | ||
Operating room | 33(8.03) | 65.3 ± 9.90 | ||
Emergency Department | 21(5.11) | 59.52 ± 7.37 | ||
Other | 63(15.33) | 65.78 ± 10.74 | ||
Whether underwent clinical teaching instructor | ||||
Yes | 205(49.88) | 65.82 ± 9.96 | t = 2.615# | 0.039 |
No | 206(50.12) | 63.23 ± 9.68 | ||
Whether underwent training on clinical leadership | ||||
Yes | 65(15.82) | 65.29 ± 8.87 | t = 1.585# | 0.014 |
No | 346(84.18) | 63.19 ± 9.96 | ||
Educational qualification | ||||
Associate degree | 33(8.03) | 65.73 ± 11.19 | F = 1.08* | 0.34 |
Bachelor’s degree | 357(86.86) | 63.41 ± 9.76 | ||
Master's degree and above | 21(5.11) | 62.10 ± 8.23 | ||
Note t: two independent samples t-test, F: one-way ANOVA
Items | Number of entries | Score | Equal distribution of items |
|---|---|---|---|
Total score of the Clinical Leadership Scale | 15 | 63.53 ± 9.81 | 4.24 ± 0.82 |
Challenge the current situation | 3 | 11.83 ± 2.47 | 3.94 ± 0.91 |
Motivating vision | 3 | 12.25 ± 2.24 | 4.08 ± 0.84 |
Set an example | 3 | 13.13 ± 2.20 | 4.38 ± 0.76 |
Inspiring others | 3 | 13.09 ± 2.12 | 4.36 ± 0.74 |
Motivating people | 3 | 13.23 ± 2.08 | 4.41 ± 0.74 |
Total score of the Nursing Work Environment Scale | 26 | 156.58 ± 23.47 | 5.23 ± 0.86 |
Total score of the General Self-efficacy Scale | 10 | 32.60 ± 5.59 | 3.26 ± 0.65 |
Level of clinical leadership | Total score of nursing work environment | Total score of general self-efficacy | |
|---|---|---|---|
Level of clinical leadership | 1 | ||
Total score of nursing work environment | 0.738༊༊ | 1 | |
Total score of general self-efficacy | 0.584༊༊ | 0.644༊༊ | 1 |
| Note: **P < 0.01 | |||
Items | B Value | Standard error | β | t value | P value | VIF |
|---|---|---|---|---|---|---|
Constant | 17.418 | 7.396 | 2.355 | 0.019 | ||
Male (reference: female) | 2.703 | 1.695 | 0.055 | 1.595 | 0.06 | 1.103 |
Title | 1.026 | 1.193 | 0.036 | 0.86 | 0.047 | 1.61 |
Department | -0.154 | 0.27 | -0.02 | -0.571 | 0.036 | 1.07 |
Whether underwent clinical teaching instructor Yes(reference: No) | 0.23 | 1.474 | 0.006 | 0.156 | 0.047 | 1.566 |
Whether underwent training on clinical leadership Yes(reference: No) | -0.841 | 1.663 | -0.017 | -0.506 | 0.022 | 1.062 |
Nursing work environment level | 0.455 | 0.034 | 0.6 | 13.409 | <0.001 | 1.822 |
Self-efficacy level | 0.598 | 0.142 | 0.188 | 4.212 | <0.001 | 1.812 |
| Notes: R2 = 0.558, adjusted R2 = 0.550, F = 72.642, P < 0.001 | ||||||
VIF: Variance inflation factor
Discussion
Overall clinical leadership of cardiovascular nurses was above average
The total clinical leadership score among cardiovascular nurses in this study was (63.53 ± 9.81), with an average item score of (4.24 ± 0.82), which is higher than those reported by Zhao [16] et al and Xu [17] et al. Among the various dimensions of clinical leadership scale, the highest average scores were recorded for “Inspiring others” (4.41 ± 0.74) and “Set an example” (4.38 ± 0.76), whereas the lowest was observed for “Challenge the current situation” (3.94 ± 0.91).
These findings reflect the distinctive demands of cardiovascular nursing and the professional behavioral traits of its practitioners. The elevated scores in the “Motivating people” and “Set an example” dimensions likely stem from the complex clinical profiles and extended treatment courses of cardiovascular patients, necessitating tightly coordinated team-based care. In daily practice, nurses exemplify standardized protocols—such as strict medication administration and precise vital signs monitoring—thereby modeling professional norms for the team. They also engage in consistent communication with patients and families, providing emotional support and encouragement to improve treatment adherence during rehabilitation, while fostering mutual motivation among colleagues to sustain performance under high-workload conditions [18]. While monitoring postoperative coronary heart disease patients, nurses must continuously assess heart rate and blood pressure changes while simultaneously alleviating patient anxiety [19]. This integrated responsibility demonstrates a “Set an example” attitude and concurrently inspires confidence in both patients and team members through motivational support.
The relatively low score in the “Challenging the Status Quo” dimension likely stems from several constraints. Cardiovascular nursing requires strict adherence to standardized procedures and protocols, such as those governing emergency responses for arrhythmia or volume management in heart failure. Consequently, nurses often follow established guidelines closely to minimize risks associated with deviating from approved processes [20]. Furthermore, within traditional management structures in domestic healthcare settings, nurses typically function at an operational level, with few opportunities to engage in system improvement or process optimization. The absence of structured platforms or incentives for innovation discourages initiative in reshaping existing workflows and advancing nursing quality [21]. This observation is consistent with Bai et al [22], who reported that clinical nurses generally demonstrate limited competence in promoting change. Targeted training is needed to strengthen their innovative thinking and decision-making in uncertain situations.
Analysis of factors influencing clinical leadership of cardiovascular nurses
whether underwent clinical teaching instructor
Simultaneously serving as a clinical teaching instructor emerged as a factor influencing the clinical leadership of nurses in the cardiovascular field (P < 0.05), as revealed by the multivariate linear regression analysis. Cardiovascular nurses who serve as clinical teaching instructors demonstrate higher clinical leadership levels than their non-instructor counterparts, a finding consistent with the work of Xu Kepei [13]. This difference may stem from the rigorous selection and training teaching instructors undergo, which often enhances their professional practical skills, analytical abilities, and problem-solving efficacy [23]. More importantly, by mentoring newly hired and intern nurses and modeling best practices in daily clinical care, these instructors exert leadership through example [24]. Their professional attitudes and behaviors thus function as influential models for other nursing staff. It is recommended that nursing managers include cardiovascular nurses' clinical leadership levels in the selection and assessment criteria for clinical teaching. This approach encourages nurses to focus on and improve their clinical leadership skills, enhances the quality of clinical teaching staff, improves nursing service quality, and ensures patient safety [25].
Whether underwent training on clinical leadership
The results demonstrate that clinical leadership training enhances cardiovascular nurses' clinical leadership competencies. Following such training, nurses acquired greater proficiency in communication, teamwork, and decision-making, while also developing a more systematic leadership mindset. Consequently, the clinical leadership capacity of cardiovascular nurses improved substantially. In this study, only 15.82% of nurses had participated in leadership training, a proportion lower than that reported in related study [26]. This discrepancy may reflect insufficient emphasis on clinical leadership among nurses in China. At present, leadership training primarily targets nursing managers, affording few opportunities for clinical cardiovascular nurses to engage in such programs [27]. This finding suggests that future practical work management, hospital-based training, and continuing education programs should broaden their target audience and incorporate leadership development content tailored to the clinical leadership traits and responsibilities of cardiovascular nurses. Such an approach would more effectively and precisely strengthen their clinical leadership competencies.
Nursing work environment
The findings of this study indicate that a better nursing work environment is associated with higher clinical leadership among cardiovascular nurses. Research has shown that a healthy nursing work environment can increase job satisfaction among cardiovascular nurses, alleviate professional burnout, and reduce turnover rates [28]. Cardiovascular nurses who perceive a supportive environment demonstrate greater work motivation, stronger skill development initiative, improved patient communication, and more effective interprofessional collaboration. This increased engagement facilitates both personal career progression and the development of clinical leadership abilities. Furthermore, a positive nursing work environment also fosters clinical leadership indirectly by enhancing nurses' work engagement [29]. Research has shown that nurses’ clinical leadership is shaped by personal attributes—including personality traits, self-awareness, and professional aspirations—which are themselves influenced by environmental factors in the workplace [30]. This study also confirms that the nursing work environment is a significant factor influencing clinical leadership. The findings above suggest that hospital administrators should establish a healthy work environment for cardiovascular nurses, stimulate their motivation, promote their professional development, and create favorable conditions to enhance their clinical leadership.
General self-efficacy
Self-efficacy refers to an individual's confidence in their ability to successfully perform specific actions and encompasses the belief in one's capacity to organize and execute the steps required to achieve desired outcomes [31]. The findings of this study indicate that higher levels of self-efficacy are associated with greater clinical leadership among cardiovascular nurses, in general, the findings of this study are consistent with previous research [32]. The likely reason is that nurses with higher self-efficacy tend to maintain a positive and optimistic attitude when managing clinical emergencies, demonstrating greater sensitivity to changes in their work environment [32]. Meanwhile, 73.72% of cardiovascular nurses in this study had more than five years of clinical nursing experience. As their years of service increased, both their professional knowledge and practical skills improved. These nurses were able to accurately assess their own competency levels, address various issues with greater confidence, and enhance their sense of self-efficacy.
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This enabled them to participate in clinical decision-making, engage in effective communication and collaboration with team members, and collectively achieve organizational goals. Therefore, this study recommends that nursing administrators regularly conduct self-efficacy training for cardiovascular nurses, establish measurable goals and provide constructive feedback, foster a positive work environment, motivate nurses to enhance their self-efficacy, enable effective communication, inspire colleagues to practice at higher levels of expertise [33], promote the demonstration of advanced clinical leadership within the team, and effectively achieve team objectives.Limitations
However, there are certain limitations of this study. The participants enrolled were primarily from a tertiary hospital, as a result of which we could not explore the current status and influencing factors of clinical leadership among cardiovascular nurses working in the field in secondary hospitals. Moreover, our study focused on cardiovascular nurses in Xiamen; further research should be based on broader and more representative sample sources to mitigate potential selection biases that could impact results. Thirdly, the study did not explore the association between clinical leadership cardiovascular nurses and patient outcomes, such as readmission rates for cardiovascular disease and the incidence of adverse nursing events. Future research could further analyze the actual impact of clinical leadership on nursing quality, providing more direct empirical support for strategies aimed at enhancing clinical leadership.
Conclusions
The clinical leadership of cardiovascular nurses is above average. Factors influencing their clinical leadership include serving as clinical instructors, participating in clinical leadership training, the nursing work environment, and self-efficacy. In clinical nursing practice, nursing managers should prioritize cultivating the clinical leadership of cardiovascular nurses to enhance the quality of nursing services.
Acknowledgements
The authors would like to thank all the experts for the generation of the questionnaire and the coordinators for the implement of the study. The authors would like to thank all of the nurses working in the cardiovascular field for participating in the study.
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Author Contribution
WLG completed the research design and writing of this article. CY conceived and designed the research. YHY and WLJ conducted the literature review. WLG developed the questionnaire. WLG analyzed the data and wrote the manuscript. CY critically revised the manuscript for intellectual content. All authors read and approved the final manuscript.
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Funding
This research received no specific grants from any funding agency in the public, commercial, or not-for-profit sectors.
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
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This study was conducted with approval from the Ethics Committee of Xiamen Cardiovascular Hospital, Xiamen University, No. (2024) Medical Ethics Committee No. (5). A
This study was conducted in accordance with the declaration of Helsinki. This study has obtained informed consent from all participants.Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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