Effect of Transformational Leadership on Job Satisfaction and Patient Safety Outcomes

Effect of transformational leadership on job satisfaction
and patient safety outcomes
Sheila A. Boamah, PhD, RN a,
*,
Heather K. Spence Laschinger, PhD, RN, FAAN, FCAHS b
, Carol Wong, PhD, RN c
,
Sean Clarke, PhD, RN, FAAN d
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
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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, 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 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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