Effect of Transformational Leadership on Job Satisfaction and Patient Safety Outcomes

This study investigates the effects of nurse managers’ transformational leadership behaviors on job satisfaction and patient safety outcomes. 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.

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
a Faculty of Nursing, University of Windsor, Windsor, Ontario, Canada
b Arthur Labatt Family School of Nursing, The University of Western Ontario, London, Ontario, Canada
c Arthur Labatt Family School of Nursing, The University of Western Ontario, FIMS & Nursing Building (FNB), London, Ontario, Canada
d Connell 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
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 organizations worldwide. However,
large studies across North America and Europe have
shown that health care systems are prone to error and
that the risk of adverse events is significant (de Vries,
Ramrattan, Smorenburg, Gouma, & Boermeester, 2008;
Kohn, Corrigan, & Donaldson, 1999).Adverse patient
outcomes or events are defined as unintended injuries or
complications caused by health care management
rather than the patient’s underlying disease process,
resulting in prolonged hospital stay, disability, or death
(Baker et al., 2004).The Institute of Medicine (IOM)
landmark report, To Err 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 errors (Kohn et al., 1999). Equally alarming, the
Canadian Institute for Health Information (CIHI)
* Corresponding author: Sheila A. Boamah, Faculty of Nursing, University of Windsor, Windsor, Ontario N9B 3P4, Canada.
E-mail address: [e-mail] (S.A. Boamah).
0029-6554/$ - see front matter Ó 2017 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.outlook.2017.10.004
Available online at www.sciencedirect.com
N u r s O u t l o o k x x x ( 2 0 1 7 )1 e 1 0
www.nursingoutlook.org

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 the burden in developed countries remains high. For
instance, the cost of adverse events to the Canadian
health care system was estimated at $1.1 billion in 2009
to 2010 (Etchells et al., 2012). Analogous costs have been
reported in the United States.
Despite progress in the past 15 years after the IOM
report, 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
because 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
researchers 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 current turbulent 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 four
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 to win the trust of the followers. The second
dimension, inspirationalmotivation,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 mentor
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
by shaping the quality of support, information, and
resources 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
behaviors. 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 their
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 Kanter
(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-
rials, supplies, money, time, and equipment needed to
accomplish the job. Finally, access to opportunities for
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-
ronments, nurses have collegial support and adequate
resources 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 poor
working conditions and inadequate nurse staffing were
predictors of adverse patient outcomes, such as
medication errors, pressure ulcers, pneumonia, failure
to rescue, and mortality. In a subsequent subanalysis
of Canadian data from this study, similar results were
reported (Laschinger & Leiter, 2006).In the present
study, nurse-assessed adverse patient outcomes or
events include patient falls, medication errors,
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, which make 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
rates, 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, Barriball, 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,
balanced 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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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
registered nurses (n ¼ 1,000) working in direct patient
care in acute care hospitals across Ontario was selected
from the College of Nursing provincial registry data-
base and invited to participate in this study. A total of
378 nurses responded to the questionnaire for a
response 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
reminder 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
Rater measures the five dimensions of transformational
leadership: idealized influencedattributes (four items),
idealized influencedbehaviors (five items), inspirational
motivation (four items), intellectual stimulation (four
items), and individualized consideration (four items).
Participants rated items on a five-point Likert scale
ranging 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
reflects 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
reported, 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
Figure 1 e Hypothesized theoretical model.
N u r s O u t l o o k x x x ( 2 0 1 7 )1 e 1 04

the incidence of common adverse patient outcomes or
complications during the past year. Nurses were asked
to rate the frequency of occurrence of specific adverse
events (medication error, patient falls with injuries,
pressure ulcers after admission, health care-associated
infections, and complaints from the patient and/or
family), which has occurred within the past year on a
scale from 1 (never) to 4 (frequently). An overall score
was computed by averaging the five items. In studies of
Canadian hospital-based nurses, Cronbach alpha co-
efficients of 0.75 (Laschinger & Leiter, 2006)and 0.81
(Wong & Giallonardo, 2013)were obtained, which is
within satisfactory limits. This scale has shown
acceptable validity (Aiken et al., 2001,2013;Wong &
Giallonardo, 2013). In the present study, the scale reli-
ability was 0.80.
Job Satisfaction
Job satisfaction was measured using the Global Job
Satisfaction (GJS) questionnaire adapted from the Job
Diagnostic Survey by Hackman and Oldham (1976). The
GJS is a four-item global measure of respondents’
satisfaction with their jobs and their coworkers. Re-
spondents rate items on a five-point Likert scale, with a
rating of 1 (strongly disagree), indicating the lowest
score and a rating of 5 (strongly agree), indicating the
highest score for job satisfaction. The GJS survey has
been used in nursing populations and found to have
acceptable internal consistency reliability of 0.78 and
0.85 (Laschinger et al., 2004; Purdy, Spence Laschinger,
Finegan, Kerr, & Olivera, 2010). In the present study, the
Cronbach a was 0.86.
Data Analysis
Descriptive statistics and scale reliabilities were
analyzed using the Statistical Package for the Social
Science, version 22.0 software (SPSS Inc.,Chicago, IL)
(IBM, 2014).Before testing the hypothesized model, a
preliminary CFA of the factor structure of all measures
was conducted using structural equation modeling
(SEM) analysis in AMOS (version 21.0), SPSS Inc.
(Arbuckle, 2012).SEM with maximum likelihood esti-
mation was used to test the fit between the data and the
hypothesized model. To estimate the significance of
indirect effects in the model, the bias-corrected boot-
strapping method with 1,000 iterations was performed
because it has greater statistical power in small samples
and maintains reasonable control over type 1 error rate
(Mackinnon, Lockwood, & Williams, 2004).
Using the recommendations by Hoyle (1995), the
following criteria were used to assess the model fit: chi-
square (c 2), the chi-square/degrees of freedom, the
incremental fit index (IFI), the comparative fit index
(CFI) (Bentler & Bonett, 1980), the TuckereLewis index
(TLI) (Tucker & Lewis, 1973), and the root mean square
error of approximation (RMSEA) (Browne & Cudeck,
1989).The generally agreed on critical value for IFI
and CFI is 0.90 or higher. A perfect fit means that there
is no discrepancy between the hypothesized model
and the observed. The RMSEA measures the lack of fit
between the data and the model, and values less than
0.06 indicate a good fitting model (Hu & Bentler, 1999).
Results
Participant Characteristics
The demographic characteristics of the sample are
presented in Table 1. On average, nurses were 46 years
old with 21 years of nursing experience and 12.2 years
working on their current hospital unit. Most nurses
were females (94%), and about 45% were baccalaureate
prepared and worked full time (68%) in medicale
surgical units (30%) and critical care units (30%).
Overall, characteristics of this study cohort are rela-
tively similar to those reported for all Ontario nurses
(CIHI, 2016).
Descriptive Results for Major Study Variables
Table 2 displays the means, standard deviations (SDs),
and Cronbach a reliabilities for the study variables. On
average,nurses reported a moderate degree of trans-
formational leadership in their managers (X ¼ 2.05; SD
¼ 0.99).Overall access to work environment factors
that empower nurses to work effectively was slightly
above the midpoint of the scale (X ¼ 11.91; SD ¼ 3.77;
range, 4e20). During the past year, nurses reported that
patient and/or family complaints (36%) and nosoco-
mial infections (28%) occurred occasionally to
Table 1 e Participant Characteristics
Demographic Characteristic Mean SD
Age 46.0 11.3
Years of nursing experience 21.0 11.9
n %
Gender
Female 356 94.2
Male 22 5.8
Highest level of nursing education
College nursing diploma 178 47.1
Bachelor degree in nursing 171 45.2
Master’s degree in nursing 24 6.3
PhD 5 1.4
Current employment status
Full-time 258 68.3
Part-time 90 23.8
Casual 30 7.9
Specialty of current unit
Medicalesurgical 115 30.4
Critical care 113 29.9
Maternalechild 38 10.1
Mental health 10 2.6
Geriatric/rehabilitation 7 1.9
Other/float resource unit 95 25.1
Note. SD, standard deviation.
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frequently. On average, nurses were moderately
satisfied with their jobs (X ¼ 3.05; SD ¼ 0.97) as 55% of
nurses agreed or strongly agreed with statements
regarding their satisfaction with the job.
Testing the Hypothesized Model
Measurement Model
Transformational leadership was modeled as a
second-order latent construct with five dimensions
described by Bass (1985). The measurement model re-
sults revealed acceptable factor loadings for all trans-
formational leadership subscales (0.85e0.94).
Structural empowerment was also modeled as a
second-order latent variable with subscales as reflec-
tive indicators. Factor loadings for structural empow-
erment subscales were acceptable (0.48e0.77). Finally,
the item factor loadings for adverse events (0.65e0.73)
and job satisfaction (0.74e0.86) were acceptable.
Structural Model
The hypothesized model was supported by the model
fit statistics (c2(128)¼ 267.454; p ¼ .001; IFI ¼ 0.964; TLI ¼
0.957; CFI ¼ 0.964; and RMSEA ¼ 0.054), indicating that
the data were a good fit to the model. All path estimates
were significant and in the hypothesized direction
(Figure 2). As predicted, transformational leadership
had a strong and significant positive direct effect (b ¼
0.77; p < .001) (H1) on structural empowerment, which
in turn, had a positive effect on job satisfaction (b ¼
0.86; p < .001) (H2), and a negative direct effect on
adverse events (b ¼ 0.35; p < .05) (H3). Subsequently,
nurses’ job satisfaction decreased the occurrence of
adverse events (b ¼ 0.63; p < .05) (H4). The hypothe-
sized indirect effects of transformational leadership
and structural empowerment on adverse events and
job satisfaction were significant (Table 3).
Discussion
The goal of this study was to investigate the effect of
transformational leadership on job satisfaction and
nurse-assessed adverse patient outcomes using medi-
ating mechanism of structural empowerment. To our
knowledge, this is the first study to provide empirical
support for this proposition. Perhaps the most impor-
tant finding in this study was the significant indirect
effect of transformational leadership on adverse patient
outcomes through structural empowerment. Although
transformational leadership offers a tangible solution
for creating empowering nursing work environments,
and thus improving patient safety outcomes (IOM, 2004;
Wong et al., 2013),limited studies have examined the
effect of transformational leadership on structural
empowerment. Past studies (Attari, 2013; Morrison,
Jones, & Fuller, 1997)linking transformational leader-
ship to empowerment focus on another concept of
empowerment from a psychological perspective.
Table 2 e Means, SDs, and Pearson’s Correlations Between Main Study Variables
Study Variable Mean SD a 1 2 3 4 5 6 7 8 9 10 11 12 13
1. Transformational leadership 2.05 0.99 0.98 d
2. Idealized influencedattribute 2.20 1.05 0.87 0.91* d
3. Idealized influencedbehaviour 2.17 1.09 0.90 0.91* 0.81* d
4. Inspirational motivation 2.30 1.08 0.93 0.87* 0.74* 0.80* d
5. Intellectual stimulation 1.90 1.08 0.91 0.91* 0.79* 0.78* 0.74* d
6. Individualized consideration 1.69 1.19 0.92 0.89* 0.79* 0.73* 0.67* 0.81* d
7. Structural empowerment 3.00 0.67 0.84 0.62* 0.54* 0.57* 0.55* 0.56* 0.56* d
8. Information 3.38 0.98 0.84 0.29* 0.23* 0.29* 0.29* 0.27* 0.22* 0.66* d
9. Support 2.54 0.89 0.73 0.59* 0.50* 0.54* 0.53* 0.54* 0.54* 0.74* 0.36* d
10. Resources 2.47 0.88 0.80 0.51* 0.46* 0.46* 0.43* 0.46* 0.48* 0.74* 0.26* 0.45* d
11. Opportunity 3.52 1.02 0.82 0.41* 0.38* 0.38* 0.33* 0.36* 0.39* 0.73* 0.24* 0.35* 0.45* d
12. Job satisfaction 3.05 0.97 0.86 0.57* 0.53* 0.54* 0.47* 0.50* 0.55* 0.61* 0.25* 0.41* 0.60* 0.49* d
13. Adverse events 1.83 0.63 0.80 0.13 y 0.10 0.14* 0.13 y 0.12 y 0.11 y 0.14* 0.1 0.09 0.11 y 0.13 y 0.28* d
Note. SD, standard deviation; a, Cronbach alpha.
* Correlation is significant at the .01 level (2-tailed).
y Correlation is significant at the .05 level (2-tailed).
N u r s O u t l o o k x x x ( 2 0 1 7 )1 e 1 06

The findings of this study suggest that trans-
formational nurse managers improve patient care
quality by creating work environments that enable
nurses to feel empowered to provide optimal care.
Consistent with other studies, positive leadership
styles, including transformational leadership behav-
iors, have been linked to better patient outcomes and
fewer complications. For instance, in a study of Cana-
dian nurses, Higgins (2015) found that nurses’ percep-
tions of their managers’ transformational leadership
behaviors had negative effects on objectively
measured adverse events (i.e., patient falls and hospi-
tal infections) through supportive practice environ-
ments and organizational citizenship behaviors. Wong
and Giallonardo (2013) found that authentic leadership
was significantly associated with decreased nurse-
assessed adverse events through trust in the manager
and areas of work life. Others have shown that trans-
formational leadership supports quality of nursing
care and clinical expertise (McGuire & Kennerly, 2006).
In this study, nurses perceived their managers as
moderately transformational. Notably, the trans-
formational leadership component, inspirational moti-
vation, had the strongest impact on nurse and patient
outcomes, whereas individualized consideration was
the lowest ranked factor. By means of inspirational
motivation, transformational leaders communicate
high expectations to followers, which inspire them to
become committed to and involved in efforts to realize
the shared vision in the organization (Avolio et al., 1999;
Bass, 1998).Transformational leaders are charismatic
and influential in their ability to encourage employees
to do more than what is expected of them at work. To
achieve success, transformational leaders provide em-
ployees with a clear sense of mission, how their work
fits with the overall goals of the organization, a sense of
commitment to those goals, and how to encourage
others to follow. In addition, these leaders attend to the
needs of nurses by acting as mentors and coaches,
listening to staff concerns, and fostering a supportive
environment for individual growth (Bass,1998).When
nurses perceive that their manager is taking interest in
their self-development and empowering them to reach
their full potential, they become more confident and
engaged at work, which ultimately, improve patient
care quality (Purdy et al., 2010; Spence Laschinger, 2008).
It is reasonable to expect that transformational
nurse managers may influence the frequency of
adverse events on their units because such leaders
encourage evidence-based practice and for employees
to think of alternative solutions for problems (Avolio
et al., 1999) and ways to improve outcomes of care. A
leader practicing transformational leadership empha-
sizes the benefits of collaboration that create a culture
where dialog is open and new ways of thinking are
encouraged. Such leaders empower nurses to solve
problems, influence change in practice on their units
(Cook, 1999), and take responsibility in the care of pa-
tient, and in doing so, may lead to fewer errors.
In the present study, nurses reported moderate
levels of empowerment in their workplace, which was
similar to perceptions of empowerment reported in
Figure 2 e Structural equation modeling results of the hypothesized model.
Table 3 e Total Indirect Effect of Leadership on Outcome Variables
Structural Paths b b SE CR p
Indirect effects
Transformational leadership / Structural empowerment
/ Job satisfaction
0.620 0.613 0.033 12.743 <.001
Transformational leadership / Structural empowerment
/ Adverse patient outcomes
0.069 0.139 0.054 2.573 <.01
Note. b, unstandardized coefficient; b, standardized coefficient; SE, standard error; CR, critical ratio.
N u r s O u t l o o k x x x ( 2 0 1 7 )1 e 1 0 7

other studies with Ontario nurses (Laschinger et al.,
2009a, 2009b; Pineau Stam, Laschinger, Regan, &
Wong, 2015).The results suggest that when nurses
have access to information (i.e., clinical quality mea-
sures, budget, and financial information) and influence
over resources supporting practice and ability to
participate in organizational decisions, it encourages
the use of clinical leadership practices at the bedside,
thereby contributing to job satisfaction. More pro-
foundly, the strong and direct relationship between
staff empowerment and nurse job satisfaction in-
dicates that enhancing the quality of the work envi-
ronment may be the most important retention
strategy. This is in line with previous research (Lautizi,
Laschinger, & Ravazzolo, 2009; Pineau Stam et al.,
2015),in which structural empowerment influences
nurses’ job satisfaction and organizational commit-
ment (Laschinger et al., 2009a,b),work engagement
(Boamah & Laschinger,2014),lower levels of burnout
and job strain (Laschinger et al., 2001),and turnover
intentions (Cai & Zhou, 2009; Laschinger et al., 2009), all
of which impact recruitment and retention of nurses.
The findings of this study are consistent with
transformational leadership theory, which highlights
the role of the leader in providing employees with
supportive work environments resulting in higher
levels of satisfaction and work effectiveness (Bass,
1998). By developing strong relationships, trans-
formational leaders understand and anticipate the
needs of their staff and make great efforts to influence
the acquisition of resources needed to increase nurses’
feelings of empowerment. Empowered nurses seek
innovative approaches to perform their job, and
thereby improving patient care outcomes and gener-
ating a greater sense of job satisfaction.
Limitations
The primary limitation of this study is the cross-
sectional nature of the study design, which limits the
interpretation of causality to the evidence of covaria-
tion in the study variables and the foundational theo-
retical associations (Polit & Beck, 2012).Longitudinal
designs examining transformational leadership in
managers and how they influence the work environ-
ment and nurse and patient safety outcomes during
time should be considered for future research. Also, it
is important to note that other important variables (i.e.,
staffing) could be added to the study model to provide a
more comprehensive understanding of the effects of
work environment on care quality. This should be
addressed in further research. Another limitation is the
use of self-report measures, which have potential for
response bias (Podsakoff & Organ, 1986). However,
having nurses anonymously complete the study
questionnaire in the privacy of their home may have
reduced bias by providing confidentiality and reducing
fear of reprisal (Podsakoff & Organ, 1986). Despite the
precise measurement of constructs in this study, the
subjective or perception-based assessment (i.e., the
use of nurse reports of adverse patient outcomes)
represents only an estimate of adverse events, which
might be subject to bias. Therefore, inclusion of
multisource data such as objective ratings of actual
patient outcomes could lessen this risk and add to the
findings of this study. Finally, although the sample was
representative of nurses in the province with respect to
age, experience, and level of education, only 38% of the
sample responded to the survey. In anticipation of
lower response rates commonly associated with mail
surveys particularly among health care professionals
(Cho, Johnson, & VanGeest, 2013), measures were
taken to promote responses (Dillman et al., 2014). This
study also used a random sample of nurses working in
acute care hospitals to decrease potential differences
between responders and nonresponders.
Conclusion
In summary, the findings of this study underscore the
important role that transformational leaders play in
enhancing the quality of the work environment for
nurses to produce better outcomes for patients. The
results contribute to a small but growing body of
empirical evidence showing an association between
relational leadership and patient outcomes. Findings
from this study suggest that transformational leader-
ship is paramount for improving patient safety and
increasing nurses’ satisfaction at work. Given the
prevalence of adverse events in hospitals and the
critical shortage of nurses, it is crucial that managers
engage in transformational leadership behaviors to
ensure that work environments are empowering to
support professional practice behaviors of nurses,
which in turn, lead to better outcomes for patients and
subsequently, improve nurse retention.
Acknowledgments
Sincere gratitude goes to the registered nurses who
participated in this study and the Western University
Dissertation Scholarship for their funding resources.
This study was funded in part by the Canadian Nurses
Foundation, the Ontario Graduate Scholarship, and
contributions from the Registered Nurses Association
of Ontario’s Research, and Education Interest Group
grants.
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