Effect of transformational leadership on job satisfaction and patient safety outcomes

Highlights

• Nursing leadership is pivotal to providing high-quality patient care and ensuring favorable organizational outcomes.

• Transformational leadership indirectly influences nurses' job satisfaction and prevalence of adverse patient outcomes through workplace empowerment.

• Managers who demonstrate transformational leadership in the workplace have greater potential to create environments that support professional nursing practice that promote high-quality patient care.

• Health care administrators need to consider change of policies to improve the work environment by providing leadership development and mentorship opportunities for existing and aspiring managers.

Abstract

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 managers' 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.

Finding

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 outcomes. 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.

Introduction

Safety and quality of patient care is recognized as a priority 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 et al., 2008, Kohn et al., 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) estimates that in more than 138,000 hospitalizations in Canada in 2014 to 2015, about 30,000—or 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 et al., 2002, Institute of Medicine, 2004). Researchers have linked patient safety outcomes to the quality of nursing work environments and lack of effective leadership (Aiken et al., 2002, Institute of Medicine, 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 leadership 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 empowerment 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 expectations of workers and to strive for excellence (Bass & Avolio, 1994). Studies have shown that transformational 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, Institute of Medicine, 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.

This study integrates concepts from the transformational 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 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 behaviors) 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 stimulation, 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 consideration, 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 suggests that the four dimensions of transformational leaders may serve as antecedents to creating structurally 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. Transformational leadership behavior is frequently associated with higher levels of employee satisfaction (Walumbwa, Orwa, Wang, & Lawler, 2005), organizational performance, follower work engagement (Zhu, Avolio, & Walumbwa, 2009), and employees' willingness 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 between 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 environments that support professional nursing practice and thus, promote better outcomes for patients and nurses. 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 meaningful manner.

The theory of structural empowerment by Kanter (1993) explains how leaders can influence employees to accomplish their work effectively by providing access to these four organizational structures: information, support, resources, and opportunities. Access to information refers to having knowledge of organizational goals, values, and policies as well as the technical knowledge and expertise required to be effective at work. Access to support includes guidance and feedback provided by peers, subordinates, and supervisors, as well as social and emotional support from colleagues. Access to resources refers to having materials, supplies, money, time, and equipment needed to accomplish the job. Finally, access to opportunities for mobility and growth entails access to challenges, rewards, increased status, recognition for competence and skills, and professional development opportunities that increase one's knowledge and skills (Kanter, 1993, Laschinger et al., 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 hospital characteristics, such as higher levels of nurse autonomy, control, and better relations with physicians (Laschinger et al., 2003, Upenieks, 2003). When working in empowering environments, nurses have collegial support and adequate resources required for high-quality patient care (Armstrong and Laschinger, 2006, Laschinger et al., 2003). Structural empowerment has been shown to be a significant predictor of higher nurse job satisfaction (Cicolini et al., 2014, Laschinger et al., 2004), work engagement (Boamah & Laschinger, 2014), organizational trust and commitment (Laschinger et al., 2001), turnover intentions (Laschinger, 2012), and improve quality of care (Donahue, Piazza, Griffin, Dykes, & Fitzpatrick, 2008). Researchers suggest that nurses led by transformational leaders may experience increased structural empowerment leading to improved working conditions and high-quality outcomes (Laschinger and Leiter, 2006, Spence Laschinger, 2008).

The primary concern of any health care delivery system, 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 (Institute of Medicine, 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 patient and/or family complaints as perceived by nurses not from administrative or regulatory database sources. 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 associated 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 is an important nursing outcome, which is affected by quality of the work environment. Despite the voluminous research that has been conducted on job satisfaction, high levels of job dissatisfaction among nurses still persist (Hayes et al., 2010, Lu et al., 2012). A growing body of research has linked the quality of nurse work environment and nurse job satisfaction (Laschinger et al., 2004, Laschinger, 2012). It was found that the characteristics of the work environment, pace, balanced workload, relations with coworkers, professional opportunities, and the ability to meet patients' needs influenced job satisfaction. Researchers (Boamah et al., 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 environment 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 individuals and patient outcomes. The present study draws from theory and research to propose a theoretical model linking transformational leadership to workplace empowerment and, subsequently, to nurse job satisfaction and nurse-assessed adverse patient outcomes.

The hypothesized model illustrating the proposed relationships is depicted in Figure 1. Overall, it is hypothesized 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).