transformational nursing leadership and effects...

Running head: TRANSFORMATIONAL NURSING LEADERSHIP AND EFFECTS ON 1

Transformational Nursing Leadership and Effects on Job Satisfaction: An Integrated Literature

Review

Karen Fugate

University of Central Florida

TRANSFORMATIONAL NURSING LEADERSHIP AND EFFECTS ON 2

Abstract

Aim. To critique the evidence that examines the impact of transformational leadership compared

to other leadership styles on nurse job satisfaction in the hospital setting.

Background. Nursing shortages and escalating clinical demands on staff can lead to job

dissatisfaction and subsequent nurse turnover. The leadership styles of nurse managers can

influence staff nurse job satisfaction. Therefore it is of utmost importance to identify the

leadership style associated with the highest level of staff nurse job satisfaction.

Design. An integrated literature review.

Method. Searches of CINAHL, PubMed, and the Cochrane Library between 1999 - February

2014. Included articles were appraised and synthesized into a narrative summary.

Conclusions. Results indicate there is a positive correlation between transformational leadership

and increased nurse job satisfaction in the hospital setting. Conversely, task focused and passive

leadership styles are negatively correlated with nurse job satisfaction.

Relevance to clinical practice. Transformational leadership is the preferred leadership style to

increase nurse job satisfaction. Transformational leadership must be supported and nurse leaders

should be encouraged to develop knowledge and skills related to transformational leadership.


Transformational Nursing Leadership and Effects on Job Satisfaction: An Integrated Literature

Review

Significance

Healthcare organizations are systems where human resources are the most important

factor for the delivery of quality healthcare; nursing is the largest workforce within the

healthcare organization. Nurses are the front line healthcare providers who spend more time with

patients than any other healthcare professional. Therefore achieving optimal healthcare delivery

is difficult, if not impossible without the efforts and commitment of staff nurses. Nursing

leadership has a significant impact on creating practice environments that support and motivate

staff nurses to provide the highest level of care to healthcare consumers.

The concept of job satisfaction is of paramount importance to nursing leadership. Nurse

satisfaction has been linked to positive patient outcomes (Aiken, Clark, Sloane, Sochalski, &

Silber, 2002). Nursing job satisfaction is also critical for nurse retention; dissatisfied nurses are

more likely to quit resulting in high turnover rates within the healthcare organization (Larrabee et

al., 2003, Weberg, 2010). The economic implications of high nurse turnover to the healthcare

organization cannot be understated. The loss of an experienced nurse can lead to short staffing,

increased recruitment and orientation costs, increased adverse patient outcomes and

consequently higher staff dissatisfaction (Hayes, Bonner, & Pryor, 2010). It is estimated that the

cost to replace a nurse is between $22,000 and $64,000 with the loss of experienced nurses being

especially costly as it takes years to develop nursing expertise (Robert Wood Johnson

Foundation [RWJF], 2009). On a more national scale, job dissatisfaction may result in nurses

leaving the profession altogether which further exacerbates the current nursing shortage

(American Association of Colleges of Nursing [AACN], 2014). McHugh et al. (2011) found


patient satisfaction levels to be lower in hospitals with higher nurse dissatisfaction rates.

Additionally, job satisfaction has been linked to higher overall life satisfaction which indicates

how satisfied the nurse is with life in general and how well their physical and psychological

needs are being met (Hayes, Bonner, & Pryor, 2010). Many factors influence nursing job

satisfaction; a factor receiving much attention lately is nursing leadership (Cummings et al.,

2010).

According to Cummings et al. (2010), leadership includes four elements: 1) leadership is

a process, 2) involves influence, 3) occurs within a group context, and 4) involves achieving

common goals. Within healthcare there are several leadership styles that can be grouped into

relationally focused or those that focus on people and relationships and task focused (non-

relationally focused) or those that focus on tasks to be completed (Cummings et al., 2010). The

relationally focused group includes transformational leadership, individualized consideration,

and resonant leadership; the task focused group includes management by exception, laissez-faire,

transactional, dissonant, and instrumental leadership styles (Cummings et al., 2010).

The transformational leader has the relational skills to motivate followers to do more than

they originally intended and more than they thought they were capable of (Cummings et al.,

2010). The transformational leader embodies several traits including expanding and elevating the

interests of their followers, building awareness and commitment to the organizational mission,

and facilitating followers to transcend their own self-interests for the betterment of the team

(Weberg, 2010). The transformational leader inspires and engages followers.

Nursing job satisfaction is related to patient clinical (Aiken et al., 2002) and satisfaction

outcomes (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011), nurse retention (RWJF,

2009, AACN, 2014), and overall life satisfaction (Hayes et al., 2010). Nursing leadership style


influences nurse job satisfaction (Cummings et al., 2010). It is imperative that nurse leaders

understand which leadership style has the most impact on nurse job satisfaction. This leadership

style should be encouraged and developed to enhance nurse job satisfaction. Transformational

leadership has been given much attention recently; however does it positively impact nurse job

satisfaction? To gain insight into transformational leadership compared to other leadership styles

and their effect on nurse job satisfaction, the following PICO question was formulated to guide

the literature review: How does transformational leadership (I) compared to other leadership

styles (C) influence job satisfaction (O) for the hospital staff nurse (P)?

Methods

A literature search was conducted to answer the PICOT question, how does

transformational leadership (I) compared to other leadership styles (C) influence job satisfaction

(O) for the hospital staff nurse (P). The search was conducted in the following databases:

Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and Cochrane

Database of Systematic Reviews. Key search terms included singly or in various combinations:

nurse, “staff nurse”, leadership, “leadership styles”, “transformational leadership”, “nurs*

leadership”, “nurs* leadership styles”, “job satisfaction”, satisfaction, “nurs* job satisfaction”,

and “nurs* work environment”. A manual search was also conducted using the ancestry

approach by reviewing the reference lists of each selected article to identify additional journal

articles. The search was limited to quantitative research articles that examined the influence of

transformational leadership compared to other leadership styles on acute care nurse job

satisfaction. Additionally, the search was limited to articles published in the last fifteen years.

Exclusion criteria were also considered while extracting relevant articles. Articles measuring job

satisfaction in nurse managers or nurse administration were excluded. Articles measuring quality


of work environment or work life that did not specifically measure job satisfaction were

excluded as were articles measuring satisfaction with leadership. Articles that did not include

transformational leadership or compare transformational leadership to at least one other

leadership style were not included. Additionally, articles that addressed nurse satisfaction in a

setting other than acute care were excluded (i.e. outpatient, elder care, long term acute care or

skilled nursing facility setting). Lastly, level of evidence and quality of the articles was taken

into consideration. The Rating System for the Hierarchy of Evidence of Intervention/Treatment

Questions (Melnyk & Fineout-Overholt, 2011) was utilized to rate the quality of the articles. The

articles were selected for their validity, reliability, and applicability with reference to the PICOT

question.

Results

Search results

Despite a comprehensive search, there were few research studies related to

transformational leadership’s effect on nurse job satisfaction compared to other leadership styles.

A total of fifty-three articles were identified from database searches: twenty-eight from

CINAHL, twenty-five from PubMed, and zero from the Cochrane Database of Systematic

Reviews. Additionally, three articles were identified via the ancestry method from a manual

review of article reference lists.

Of the CINAHL articles, five were included and twenty-three were eliminated. Four

were eliminated because they were in a non-hospital setting – two elder care, one long-term care

facility, and one ambulatory care. Five did not address nurse job satisfaction specifically and four

measured job satisfaction in managers, leaders, and faculty. Four did not include

transformational leadership style as one of the measures and one evaluated transformational


leadership only. Five articles were commentaries and or exemplars and were eliminated for their

lack of quantitative evidence. The PubMed search identified twenty-five articles. Twenty-one of

the articles were duplicates of the CINAHL search. Of the four remaining articles, one was a

commentary, one did not evaluate nurse job satisfaction, and two did not correlate job

satisfaction with leadership style.

After review, eight articles were found to be suitable for appraisal and pulled as full text

– five from the CINAHL search and three identified through review of article reference lists.

Upon evaluation, all eight articles were found to be relevant to the PICOT question. There were

no randomized controlled trials or controlled trials without randomization. The level of evidence

for this literature review consisted of two Level V articles (systematic reviews of descriptive and

qualitative studies) and six Level VI articles (single descriptive or qualitative studies) (Melnyk &

Fineout-Overholt, 2011).

A summary of the design, level of evidence, sample characteristics and results for each of

the eight articles included in the integrated literature review are included as tables. The articles

are organized alphabetically by first author and are classified into the following three themes

based on the influence of nurse leadership style on job satisfaction (Table 1), nurse work

environment (Table 2), and nurse manager outcomes (Table 3).

Job satisfaction

Two studies (Abualrub & Alghamdi, 2012; Failla & Stichler, 2008) and one evidence

review (Weberg, 2010) address the impact of leadership style on job satisfaction (see Table 1).

When transformational leadership was compared to other leadership styles, transformational

leadership was related to increased job satisfaction whereas other leadership styles were

associated with decreased job satisfaction. Abualrub and Alghamdi (2012) and Failla and

Stichler (2008) report a significant and moderate positive relationship between transformational


leadership and job satisfaction (r = 0.45 and 0.38 respectively). Failla and Stichler (2008) also

report positive correlations between transformational subscales and job satisfaction; the strongest

correlation (r = 0.425) was between the transformational subscale “attributed idealized

influence” and job satisfaction indicating the leader that is seen as charismatic, powerful and

confident is more likely to have staff that are satisfied with their job. Conversely, negative

correlations are reported between transactional, passive avoidance and laissez-faire leadership

styles and job satisfaction; laissez-faire had the strongest negative correlation (Abualrub &

Alghamdi, 2012; Failla & Stichler, 2008). In addition to the findings in the two studies, Weberg

(2010) evaluates seven articles in his evidence review and concludes that transformational

leadership increases job satisfaction and transactional and laissez-faire leadership lead to poor

job satisfaction.

One of the two studies was conducted in Saudi Arabia strengthening the argument and

indicating the findings are not limited to the United States (Abualrub & Alghamdi, 2012). Both

studies use validated psychometric tools to measure leadership style and job satisfaction. The

Multi-factor Leadership Questionnaire (MLQ) is utilized in both studies to measure leadership

style which provides for consistent measurement of leadership traits.

Table 1: Studies related to job satisfaction

Primary Study,

Country

Design, Level of Evidence, Sample

Characteristics of Intervention

Results

Abualrub et al. (2012) Saudi Arabia

Descriptive correlational designLevel VIA convenience sample of staff RNs working in 6 public hospitalsn = 308

No direct intervention.The study was designed to examine the impact of leadership styles (transformational and transactional) on levels of intent to stay at work and job satisfaction among hospital nurses. A structured

There was a significant correlation in the positive direction between job satisfaction scores and transformational leadership style (r = 0.45, P <0.001).Conversely, there was a significant correlation in the negative direction between


Primary Study,

Country



Results

questionnaire combining the Multifactor Leadership Questionnaire (MLQ-5X), Job Satisfaction Survey (JSS), and McCain’s Intent to Stay Scale was used to collect data and measure the study variables.

job satisfaction scores and transactional leadership style (r = - 0.14, P < 0.01).Results of hierarchical regression analysis indicated that 32% of variation in job satisfaction was explained by the background variables, transformational and transactional leadership style.

Failla et al.(2008) United States of America

Cross-sectional, descriptive correlational designLevel VIA convenience sample drawn from a population of nurses and nurse managers in a large metropolitan hospital campusn = 92 (76 staff nurses)

No direct intervention.Data were collected from self-administered questionnaires. The Multifactor Leadership Questionnaire (MLQ) was used to measure leadership characteristics and the Index of Work Satisfaction Questionnaire – Part B (IWS-B) was used to measure work satisfaction. The intent of the study was to answer 4 research questions, one of which was the relationship between nurse manager’s leadership style and level of job satisfaction among his/her staff.

Significant and positive correlations were demonstrated between aggregate scores of work satisfaction and transformational leadership style overall and in 4 subscales of the MLQ:Transformational leadership overall – r = 0.348a

Attributed idealized influence – r = 0.425a

Behavioral idealized influence – r = 0.265a

Inspirational motivation – r = 0.413a

Intellectual stimulation – r = 0.282a

Transactional leadership showed a statistically positive correlation in one subscale only (contingent reward – r = 0.0328a and passive-avoidant leadership showed statistically negative correlation overall (r = -0.0241a) and laissez-faire (r = -0.290a)aSignificant at <.05 level

Weberg (2010) United States of

Evidence reviewLevel V7 studies were included in the

No direct intervention.The evidence review was conducted to answer the PICO question “In healthcare

3 studies evaluated leadership style and influence on staff satisfaction (2 were conducted in large acute care


Primary Study,

Country



Results

America final evaluation of evidence. All were quantitative in design and used correlational, non-experimental, or cross-sectional designs.

organizations (P), how does transformational leadership (I) influence staff satisfaction and job burnout (O)?”

hospitals and one in an elder care center).When transformational leadership was compared with other leadership styles looking at staff satisfaction as an outcome, transformational leadership was related to an increase in staff satisfaction in healthcare organizations whereas other leadership styles were related to a decrease in staff satisfaction.

Work environment

Two studies (Larrabee et al., 2003; Malloy & Penprase, 2010) and one systematic review

(Cummings et al., 2010) are included to address the impact of leadership style on the nurse work

environment (see Table 2). As in the “job satisfaction” theme, the MLQ is utilized in both studies

ensuring a consistent method to measure leadership traits. Both studies utilize a conceptual

model suggesting they were guided by a theoretical framework which strengthens the validity of

the study findings. Larrabee et al. (2003) study nurse job satisfaction compared to work

environment variables of context of care, structure of care, and nurse attitudes; work

environment context variables include leadership styles. Larabee et al. (2003) reveal a significant

strong positive correlation between nurse job satisfaction and transformational leadership (r =

0.53) and a significant moderate negative correlation between more passive leadership styles -

management by exception and laissez faire. Malloy and Penprase (2010) examine the correlation

between leadership style components and psychosocial work environment dimensions one of

which is job satisfaction. Malloy and Penprase (2010) report significant positive correlations


between all components of transformational leadership and job satisfaction; the strongest

correlations are between idealized influence attributes, inspirational motivation, and intellectual

stimulation. Cummings et al. (2010) conduct a systematic review of the relationship between

leadership styles and nursing workforce and work environment outcomes; outcomes are grouped

into five categories one of which is staff satisfaction with work. Upon review of fifty-three

articles, Cummings et al. (2010) report a positive association between relationship-focused

leadership styles such as transformational leadership and higher nurse job satisfaction in twenty-

two studies, whereas ten studies reveal leadership styles focused on tasks are correlated with

lower nurse job satisfaction.

All three articles report a positive relationship between leadership styles that fit the

transformational form of leadership and job satisfaction. They also reported lower job

satisfaction with more task focused forms of leadership such as management by exception and

laissez-faire leadership. This is consistent with findings in the aforementioned “job satisfaction”

theme.

Table 2: Studies related to work environment

Primary Study,

Country



Results

Cummings et al. (2009) Canada

Systematic reviewLevel V53 total studies were included which were all quantitative in design and used correlational, non-experimental, or cross-sectional designs

No direct intervention.The specific aim of the review was to systematically review the literature to examine the relationships between various styles of leadership and outcomes for the nursing workforce and their work environments. Studies were divided into 5 themes which investigated the outcomes of leadership on,

Nursing satisfaction was the most frequently examined outcome of leadership (24 studies). Twenty-two studies reported highest job satisfaction with a variety of relational focused leadership styles including transformational leadership. Two studies found that relational leadership styles were not significantly associated with job


Primary Study,

Country



Results

1) staff satisfaction, 2) staff relationships with work, 3) staff health and well-being, 4) work environment factors, and 5) productivity and effectiveness.

satisfaction. Ten studies reported job satisfaction was significantly lower with more task focused forms of leadership.

Larrabee et al. (2003) United States of America

Non-experimental, descriptive designLevel VINonrandom sample of RNs in a large university hospital (n = 90)

The purpose of the study was to examine the relative influence on nurse attitudes, context of care, and structure of care on job satisfaction and intent to leave. Several instruments with known psychometric properties were utilized including the Multifactor Leadership Questionnaire to measure nurse manager leadership style and the Work Quality Index (WQI) to measure RN job satisfaction.

Multivariate regression analyses evaluated models that best predict RN job satisfaction.Pearson correlation between RN job satisfaction and:Transformational leadership – r = 0.53, P < 0.0001Contingent reward – r = 0.52, P < 0.0001Management by exception (passive) – r = -0.041, P <0.0001Laissez-faire leadership – r = -0.42, P < 0.0001

Malloy et al. (2010) United States of America

Correlational designLevel VIConvenience sample of RNs working for a government agency - n = 122 (35 supervisory and 87 non-supervisory)

No direct intervention. The aim of this study was to examine the relationship between leadership style and the psychosocial work environment of registered nurses. The Multifactor Leadership Questionnaire 5X was used to evaluate leadership style and the Copenhagen Psychosocial Questionnaire was used to measure psychosocial work environment.

Correlations between leadership model components and job satisfaction measured by Pearson’s r (*P < 0.05, **P < 0.01). Components of transformational leadership have a higher correlational with job satisfaction than transactional and passive-avoidance leadership components (see below).Transformational Leadership components: Idealized Influence-Attributes (0.48**), Individual Consideration (0.44**), Idealized Influence-Behavior (0.39**)Inspirational Motivation (0.48**), Intellectual Stimulation (0.48**)Transactional Leadership


Primary Study,

Country



Results

components:Contingent Reward (0.45**), Management by Exception-Active (-0.21*)Passive-Avoidance Leadership:Management by exception-passive (-0.44**), Laissez Faire (-0.53**)

Nurse manager outcomes

Two studies (Cassida & Parker, 2011; Dunham-Taylor, 2000) are included to address the

final theme of influence of leadership style on nurse manager outcomes (see Table 3). As in the

previously described themes, both studies utilize the MLQ to measure leadership traits; however

these two studies also use the MLQ to evaluate the nurse manager outcomes of leader’s extra

effort, leadership effectiveness, and leadership satisfaction (LS). Leadership satisfaction

indicates the manager’s ability to meet the needs of the staff nurse through positive

communication, interaction, and increased visibility, thereby keeping staff nurses satisfied with

their work (Cassida & Parker, 2011). Both studies report significant positive correlations

between transformational (r = 0.82 and 0.79) and transactional (r = 0.27 and 0.37) leadership

styles and LS; however there was a stronger relationship between transformational leadership

and LS (Cassida & Parker, 2011; Dunham-Taylor, 2000). Moreover, Casida and Parker (2011)

report the best predictor for the LS variable to be idealized influence attributes; this result is

similar to findings in previously mentioned studies conducted by Failla and Stichler (2008) and

Malloy and Penprase (2010).


Table 3: Studies related to nurse manager outcomes

Primary Study,

Country



Results

Casida et al. (2011) United States of America

Exploratory correlational designLevel VISample derived from 4 hospitals in Northeast U.S. – staff nurses (n = 278, nurse managers (n = 37)

No direct intervention.Staff nurses were asked to evaluate the leadership style and outcomes of nurse managers using the Multifactor Leadership Questionnaire Form 5x-Short. Outcomes included leader’s extra effort (LEE), satisfaction with leader (LS), leadership effectiveness (LE). All 3 outcomes are associated with nurse job satisfaction.

Correlations among nurse manager leadership styles and outcomes were measured using Pearson’s r. Asterisk denotes statistical significance P <0.0001.Transformational leadership demonstrates positive, strong, significant correlations with LEE, LS, and LE (0.83*, 0.82*, 0.89*). There was a significant weakly positive correlation between transactional leadership and LEE, LS, and LE (0.29*, 0.27*, 0.28*).

Dunham-Taylor (2000) United States of America

Descriptive, correlational designLevel VIRandom sample of nurse executives from full-service or children’s general hospitals in the U.S. (n = 396) and the staff reporting to the nurse executive (n = 1,115)

No direct intervention.Study aimed to examine transformational leadership and outcomes (see below), stage of power, and organizational climate. Nurse executives and staff reporting to them rated the nurse executive’s leadership style and outcomes of staff extra effort, staff satisfaction, and work group effectiveness using the Multifactor Leadership Questionnaire. Executives’ bosses rated work group effectiveness. Nurse executives rated their stage of power using Hagberg’s Personal Power Profile and ranked their organizational climate using Likert’s Profile of Organizational Characteristics.

As staff rated nurse executive transformational leadership as occurring more frequently, they rated their satisfaction with leadership to increase. This relationship was strongly positive and statistically significant (r = 0.79, P < 0.0001). Staff satisfaction with leadership style decreased as staff rated the executive as being more transactional (r = 0.37, P < 0.0001).


Limitations of evidence

Only published studies were included in this review which may contribute to reporting

bias since published work tends to reflect positive findings. An additional limitation of this body

of evidence is that the data in all the studies were obtained from surveys. Survey study

limitations include respondent bias secondary to convenience sampling. Notable also was the

low survey response rate (<60%) in several of the studies (Abualrub & Alghamdi, 2012; Failla &

Stichler, 2008; Larrabee et al., 2003; Malloy & Penprase, 2010); better response rates would

improve reliability of the results. Another limitation is that there were no randomized controlled

trials; although logistically challenging, this type of evidence would have been helpful. This is

due in part to the nature of studying leadership; the specific leadership style populations are most

easily studied by convenience sampling. Additionally, the single site sample of some of the

studies and small sample size limit generalizability (Failla & Stichler, 2008; Larrabee et al.,

2003; Malloy & Penprase, 2010). Conversely, the consistent use of the MLQ increases the

validity and generalizability of the study results. Limitations are also lessened by the consistent

findings across studies correlating transformational leadership with job satisfaction (r = 0.348,

0.45, 0.53, 0.79, 0.82).

Recommendation for Practice

The research for the PICO question, how does transformational leadership (I) compared

to other leadership styles (C) influence job satisfaction (O) for the hospital staff nurse (P)

resulted in indicating that transformational leadership compared to other leadership styles has a

positive impact on nurse job satisfaction. The nurse manager who displays transformational

leadership qualities will have higher staff nurse satisfaction. Therefore, it is recommended that

transformational leadership is the preferred leadership style to increase nurse job satisfaction.


Nurse leaders practice multiple styles of leadership. Leadership theory depicts a

continuum of leadership styles ranging from highly engaged on one end of the spectrum

(transformational leadership) to highly avoidant on the other end. Currently many healthcare

leaders are primarily task focused (Cummings et al., 2010). According to Cummings et al.

(2010) and Cassida and Parker (2011), transformational leadership skills can be learned. Hence,

transformational leadership training and mentoring should be offered for nurse leaders to

encourage and develop knowledge and skills related to transformational leadership. Furthermore,

there should be a strong focus on idealized influence attributes as this is the transformational

leadership characteristic most predictive of higher nurse job satisfaction (Cassida & Parker,

2011; Failla & Stichler, 2008; Malloy & Penprase, 2010).

If healthcare is going to effectively confront a rapidly changing, complex environment, it

will need to invest energy and resources into developing insightful, visionary, competent,

motivational leaders that will positively affect nurse job satisfaction which will ultimately

improve the quality care for healthcare consumers. Representing the largest workforce in

healthcare, the transformational nurse leader is perfectly positioned to lead this challenge. In

addition, given the looming nursing shortage and the relationship between nurse job

dissatisfaction and intent to leave (Larrabee et al., 2003; Weberg, 2010), healthcare policy should

address evidence-based strategies such as leadership style that are known to increase nurse

satisfaction. This can start with developing undergraduate and graduate nursing curriculums that

address transformational leadership education.

Future research can continue to inform practice on this very important nursing issue.

Transformational leadership skills can be taught; however little is known about what types of

leadership training are best suited to translate knowledge into action. Future research could


concern various types of leadership training and the degree to which they develop

transformational leadership traits in managers and influence nurse job satisfaction. Servant

leadership is similar to transformational leadership in that they both focus on building

relationships (American Association of Nurse Assessment Coordination [AANAC], 2013).

Research on servant leadership compared to transformational leadership and job satisfaction

could inform nursing practice as well.


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