Effect of transformational leadership on job satisfaction and patient safety outcomes
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Effect of transformational leadership on job satisfaction
and patient safety outcomes
Sheila A. Boamah, PhD, RNa,*,
Heather K. Spence Laschinger, PhD, RN, FAAN, FCAHSb, Carol Wong, PhD, RNc,
Sean Clarke, PhD, RN, FAANd
aFaculty of Nursing, University of Windsor, Windsor, Ontario, Canada
Arthur Labatt Family School of Nursing, The University of Western Ontario, London, Ontario, Canada
cArthur Labatt Family School of Nursing, The University of Western Ontario, FIMS & Nursing Building (FNB), London, Ontario, Canada
dConnell School of Nursing, Boston College, Chestnut Hill, MA
a r t i c l e i n f o
Article history:
Received 17 May 2017
Revised 28 September 2017
Accepted 16 October 2017
Keywords:
Patient safety
Transformational leadership
Empowerment
Job satisfaction
Work environment
* Co
esponding author: Sheila A. Boamah, F
E-mail address:
[email protected] (S
0029-6554/$ - see front matter � 2017 Elsevi
https:
doi.org/10.1016/j.outlook.2017.10.004
a b s t r a c t
Background: Improving patient safety within health care organizations requires
effective leadership at all levels.
Purpose: The objective of this study was to investigate the effects of nurse man-
agers’ transformational leadership behaviors on job satisfaction and patient
safety outcomes.
Methods: A random sample of acute care nurses in Ontario (N = 378) completed
the crosssectional survey. Hypothesized model was tested using structural
equation modeling.
Discussion: The model fit the data acceptably. Transformational leadership had a
strong positive influence on workplace empowerment, which in turn increased
nurses’ job satisfaction and decreased the frequency of adverse patient out-
comes. Subsequently, job satisfaction was related to lower adverse events.
Conclusion: The findings provide support for managers’ use of transformational
leadership behaviors as a useful strategy in creating workplace conditions that
promote better safety outcomes for patients and nurses.
Cite this article: Boamah, S. A., Spence Laschinger, H. K., Wong, C., & Clarke, S. (2017, -). Effect of
transformational leadership on job satisfaction and patient safety outcomes. Nursing Outlook, -(-),
1-10. https:
doi.org/10.1016/j.outlook.2017.10.004.
Introduction
Safety and quality of patient care is recognized as a pri-
ority for health care organizationsworldwide. However,
large studies across North America and Europe have
shown that health care systems are prone to e
or and
that the risk of adverse events is significant (de Vries,
Ramrattan, Smorenburg, Gouma, & Boermeester, 2008;
Kohn, Co
igan, & Donaldson, 1999). Adverse patient
aculty of Nursing, Unive
.A. Boamah).
er Inc. All rights reserved
outcomesoreventsaredefinedasunintended injurieso
complications caused by health care management
ather than the patient’s underlying disease process,
esulting in prolonged hospital stay, disability, or death
(Baker et al., 2004). The Institute of Medicine (IOM)
landmark report, To E
is Human, estimates that up to
98,000 patients die, and more than 1 million are injured
each year in the United States as a result of preventable
medical e
ors (Kohn et al., 1999). Equally alarming, the
Canadian Institute for Health Information (CIHI)
sity of Windsor, Windsor, Ontario N9B 3P4, Canada.
.
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mailto:
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Nur s Out l o o k x x x ( 2 0 1 7 ) 1e 1 02
estimates that in more than 138,000 hospitalizations in
Canada in 2014 to 2015, about 30,000dor one in every 18
patients suffered preventable harm that compromised
their care (CIHI, 2016). Research has shown that the
economic costs of adverse events are also significant,
and theburden indevelopedcountries remainshigh. Fo
instance, the cost of adverse events to the Canadian
health care systemwas estimated at $1.1 billion in 2009
to 2010 (Etchells et al., 2012). Analogous costs have been
eported in the United States.
Despite progress in the past 15 years after the IOM
eport, patient safety remains an important public
health challenge (Pronovost, Cleeman, Wright, &
Srinivasan, 2016). Studies indicate that alarmingly
high rates of adverse events in hospitals are a result of
preventable incidents, some of which are likely
ecause of nursing-related factors (Aiken, Clarke,
Sloane, Sochalski, & Silber, 2002; IOM, 2004). Re-
searchers have linked patient safety outcomes to the
quality of nursing work environments and lack of
effective leadership (Aiken et al., 2002; IOM, 2004). In
the organizational literature, relational leadership
styles (i.e., transformational leadership) have been
linked to reduced adverse patient outcomes
(Cummings et al., 2010). Few studies, however, have
investigated the mechanisms through which leader-
ship influences employee behavior and subsequent
implications on patient safety outcomes (Wong,
Cummings, & Ducharme, 2013). In the context of the
foregoing, one of the biggest knowledge gaps is how
nursing leadership and workplace factors influence
health care quality and safety outcomes. Thus, the
purpose of this study was to test a model linking
transformational leadership and structural empower-
ment to nurses’ job satisfaction and prevalence of
adverse events in acute care settings. In this study, the
esearchers examined how transformational leadership
influenced patient safety outcomes and job satisfaction
through the mediator, structural empowerment.
Transformational leadership is a behavior-based
approach to obtain performance beyond basic expec-
tations of workers and to strive for excellence (Bass &
Avolio, 1994). Studies have shown that trans-
formational leadership is key in creating supportive
work environments in which nurses are structurally
empowered to provide optimal patient care (Cummings
et al., 2010). Several authors (Gabel, 2013; IOM, 2004)
have suggested that transformational leadership styles
seem particularly relevant in cu
ent tu
ulent and
stressful health care work environments. Applying the
concept of transformational leadership to this issue
may provide insight into the ways in which leadership
can influence patient outcomes.
Theoretical Framework and Relevant Research
This study integrates concepts from the trans-
formational leadership theory of Bass (1985) and theory
of structural empowerment by Kanter (1993) to
examine how workplace factors influence patient
safety outcomes and job satisfaction. The theoretical
underpinnings of the concepts in the proposed model
are described in the subsequent paragraphs.
Transformational Leadership
Transformational leadership is a relational leadership
style in which followers have trust and respect for the
leader and are motivated to do more than is formally
expected of them to achieve organizational goals (Bass,
1985). Transformational leadership consists of fou
core dimensions: idealized influence (attributes and be-
haviors) describes a manager who is exemplary role
model for followers, sets high standards of conduct,
and is able to articulate the vision of the organization
in an effort towin the trust of the followers. The second
dimension, inspirational motivation, reflects a leader’s
clear articulation of a compelling vision through
words, symbols, and imagery (Bass, 1985) to inspire
followers to act. The third dimension, intellectual stim-
ulation, reflects the extent to which a leader solicits
employees’ perspective on problems and considers a
wide variety of opinions in making decisions (Bass,
1985). Finally, leaders engaging in individualized consid-
eration, the fourth dimension of transformational
leadership, attend to the individual differences in the
needs of their employees and seek to coach or mento
them in an effort to help them reach their full potential
(Avolio, Bass, & Jung, 1999).
Transformational leadership has consistently been
linked to employee attitudes and behaviors in both
management settings and nursing. Researcher sug-
gests that the four dimensions of transformational
leaders may serve as antecedents to creating struc-
turally empowering work environments. For instance,
through intellectual stimulation, a transformational
leader encourages employees to participate in the
decision-making process, which fosters critical
thinking and development of skills and knowledge.
Such leader creates empowering conditions for nurses
y shaping the quality of support, information, and
esources available in the workplace. Trans-
formational leadership behavior is frequently associ-
ated with higher levels of employee satisfaction
(Walumbwa, Orwa, Wang, & Lawler, 2005), organiza-
tional performance, follower work engagement (Zhu,
Avolio, & Walumbwa, 2009), and employees’ willing-
ness to exert extra effort to reach a given goal. In a
study of more than 700 nurses from seven Canadian
acute care hospitals, McCutcheon, Doran, Evans, Hall,
and Pringle (2009) found important relationships be-
tween transformational leadership behaviors of nurse
managers and job satisfaction. More recently, Higgins
(2015) found that transformational leaders improve
the quality of patient care by creating supportive
practice environment and organizational citizenship
ehaviors. These studies highlight the importance of
transformational leadership in creating work environ-
ments that support professional nursing practice and
thus, promote better outcomes for patients and nurses.
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By developing positive relationships, transformational
leaders gain trust of their followers and anticipate thei
needs by providing access to structurally empowering
factors (i.e., information, support, resources) necessary
for employees to accomplish their work in a mean-
ingful manner.
Structural Empowerment
The theory of structural empowerment by Kante
(1993) explains how leaders can influence employees
to accomplish their work effectively by providing ac-
cess to these four organizational structures: informa-
tion, support, resources, and opportunities. Access to
information refers to having knowledge of organiza-
tional goals, values, and policies as well as the tech-
nical knowledge and expertise required to be effective
at work. Access to support includes guidance and
feedback provided by peers, subordinates, and super-
visors, as well as social and emotional support from
colleagues. Access to resources refers to having mate-
ials, supplies, money, time, and equipment needed to
accomplish the job. Finally, access to opportunities fo
mobility and growth entails access to challenges, re-
wards, increased status, recognition for competence
and skills, and professional development opportunities
that increase one’s knowledge and skills (Kanter, 1993;
Laschinger, Finegan, Shamian, & Wilk, 2001).
Numerous studies have been conducted to test the
structural empowerment theory by Kanter in a variety
of nursing populations and settings. Structural
empowerment has been associated with magnet hos-
pital characteristics, such as higher levels of nurse
autonomy, control, and better relations with physi-
cians (Laschinger, Almost, & Donnalene, 2003;
Upenieks, 2003). When working in empowering envi-
onments, nurses have collegial support and adequate
esources required for high-quality patient care
(Armstrong & Laschinger, 2006; Laschinger et al., 2003).
Structural empowerment has been shown to be a sig-
nificant predictor of higher nurse job satisfaction
(Cicolini, Comparcini, & Simonetti, 2014; Laschinger,
Finegan, Shamian, & Wilk, 2004), work engagement
(Boamah & Laschinger, 2014), organizational trust and
commitment (Laschinger et al., 2001), turnover in-
tentions (Laschinger, 2012), and improve quality of care
(Donahue, Piazza, Griffin, Dykes, & Fitzpatrick, 2008).
Researchers suggest that nurses led by trans-
formational leaders may experience increased struc-
tural empowerment leading to improved working
conditions and high-quality outcomes (Laschinger &
Leiter, 2006; Spence Laschinger, 2008).
Adverse Patient Outcomes
The primary concern of any health care delivery sys-
tem, and in essence nursing, is the achievement of
optimum patient outcomes (WHO, 2005). Patient
outcome research has attributed most adverse patient
outcomes to factors in the work environment (Aiken,
Sloane, Bruyneel, Van den Heede, & Sermeus, 2013)
and lack of effective and visible leadership (IOM, 2004;
Kohn et al., 1999). Aiken et al. (2001) found that the poo
working conditions and inadequate nurse staffingwere
predictors of adverse patient outcomes, such as
medication e
ors, pressure ulcers, pneumonia, failure
to rescue, and mortality. In a subsequent subanalysis
of Canadian data from this study, similar results were
eported (Laschinger & Leiter, 2006). In the present
study, nurse-assessed adverse patient outcomes o
events include patient falls, medication e
ors,
hospital-acquired infections, pressure ulcers, and pa-
tient and/or family complaints as perceived by nurses
not from administrative or regulatory database sour-
ces. Nurse ratings of quality of care provide related yet
distinct information about patient outcomes because
nurses are involved virtually at all points of patient
care, whichmake their perspective a valuable source of
information. In a study of more than 16,000 nurses in
396 U.S. hospitals, McHugh and Stimpfel (2012) found
that nurse-assessed quality of patient care was asso-
ciated with objective hospital quality indicators, such
as patient satisfaction, failure to rescue, and mortality
ates, suggesting that the actual and nurse-perceived
evaluation of patient outcomes are entwined.
Job Satisfaction
Job satisfaction is an important nursing outcome,
which is affected by quality of the work environment.
Despite the voluminous research that has been con-
ducted on job satisfaction, high levels of job dissatis-
faction among nurses still persist (Hayes, Bonner, &
Pryor, 2010; Lu, Ba
iball, Zhang, & While, 2012). A
growing body of research has linked the quality of
nurse work environment and nurse job satisfaction
(Laschinger et al., 2004, 2012). It was found that the
characteristics of the work environment, pace,
alanced workload, relations with coworkers, profes-
sional opportunities, and the ability to meet patients’
needs influenced job satisfaction. Researchers
(Boamah, Read, & Laschinger, 2017; Cicolini et al., 2014)
have shown strong positive relationship between
structural empowerment and nurses’ job satisfaction.
Job satisfaction of nurses is critical to meeting the
challenges of quality outcomes, patient satisfaction,
and retention of nurses in hospitals (Aiken et al., 2002;
Cicolini et al., 2014; Hayes et al., 2010). Although it is
well acknowledged that effective nursing leadership is
the driving force for creating healthy work environ-
ment that fosters positive nurse and patient outcomes,
little empirical studies have been undertaken that
clearly describe and identify the direct and indirect
mechanisms by which leaders effect change in in-
dividuals and patient outcomes. The present study
draws from theory and research to propose a theoret-
ical model linking transformational leadership to
workplace empowerment and, subsequently, to nurse
job satisfaction and nurse-assessed adverse patient
outcomes.
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Figure 1 e Hypothesized theoretical model.
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Hypothesized Model
The hypothesized model illustrating the proposed re-
lationships is depicted in Figure 1. Overall, it is hy-
pothesized that higher staff ratings of their manager’s
transformational leadership would be related to
greater structural empowerment (hypothesis 1), which
in turn, would contribute to increased job satisfaction
(hypothesis 2), and lower adverse events (hypothesis
3). Higher job satisfaction would lead to lower adverse
patient outcomes (hypothesis 4).
Methods
Design and Sample
A cross-sectional predictive survey design was used to
test the hypothesized model. A random sample of
egistered nurses (n ¼ 1,000) working in direct patient
care in acute care hospitals across Ontariowas selected
from the College of Nursing provincial registry data-
ase and invited to participate in this study. A total of
378 nurses responded to the questionnaire for a
esponse rate of 38%. Eligible participants were nurses
working in direct patient care settings. After obtaining
ethics approval, participants were mailed a survey
package to their home address, including a letter of
information, a questionnaire, and prepaid addressed
envelope. Respondents had two options of partici-
pating in this study either by completing a question-
naire booklet or by an online survey. Using the
procedure of Dillman, Smyth, and Christian (2014) to
optimize response rates, nonresponders received a
eminder letter 3 weeks after the initial mailing, fol-
lowed by a second survey package 4 weeks later.
Measures
Transformational Leadership
The Multifactor Leadership Questionnaire-5X Short
Ratermeasures thefivedimensionsof transformational
leadership: idealized influencedattributes (four items),
idealized influencedbehaviors (five items), inspirational
motivation (four items), intellectual stimulation (fou
items), and individualized consideration (four items).
Participants rated items on a five-point Likert scale
anging from 0 ¼ not at all to 4 ¼ frequently, if not al-
ways. Previous research has supported the reliability
and validity (Avolio & Bass, 2004) of this instrument
among nurses (Cronbach a ¼ 0.74e0.87) (AbuAlRub &
Alghamdi, 2012; Boamah, 2017). In the present study,
the Cronbach a coefficient was 0.97.
Structural Empowerment
Structural empowerment was measured using the
Conditions of Work Effectiveness-II (CWEQ-II)
(Laschinger et al., 2001). The CWEQ-II is a 12-item
measure that consists of four core subscales (infor-
mation, support, resources, and opportunity), which
eflects the dimensions of work empowerment struc-
tures. Each subscale consists of three items rated on a
five-point scale ranging from 1 ¼ none to 5 ¼ a lot,
averaged to create subscale scores. Total empower-
ment score is measured by summing the means of the
four subscales that range from 4 to 20. Higher overall
scores represent higher perceptions of empowerment
construct. Acceptable internal consistency has been
eported, as evidenced by Cronbach a ranging from
0.78 to 0.93 in studies conducted between 1996 and
2013 (Laschinger et al., 2001, Laschinger, Wong, & Grau,
2013). The construct validity was established using
confirmatory factor analysis (CFA) (Boamah, 2017;
Laschinger et al., 2001). For the present study, the
Cronbach alpha reliabilities were adequate (0.72e0.84)
for the subscales and overall scale (0.84).
Nurse-Assessed Adverse Patient Outcomes
Staff nurses’ ratings of adverse patient outcomes were
measured using an instrument developed by Sochalski
(2001) and derived from the Nursing Quality Indicators
formulated by the American Nurses Association
(American Nurses Association, 2000). This scale com-
prises five items that assess the nurses’ perceptions of
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Table 1 e Participant Characteristics
Demographic Characteristic Mean...