Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
The articles’ data supporting this systematic review are from previously reported studies and datasets, which have been cited. The processed data are available in Table 2 and in the reference list. Further information can be requested from the corresponding author.
Background: With the increasingly demanding healthcare environment, patient safety issues are only becoming more complex. This urges nursing leaders to adapt and master effective leadership; particularly, transformational leadership (TFL) is shown to scientifically be the most successfully recognized leadership style in healthcare, focusing on relationship building while putting followers in power and emphasizing values and vision. Aim: To examine how transformational leadership affects nurses’ job environment and nursing care provided to the patients and patients’ outcomes. Design: A systematic literature review was conducted. From 71 reviewed, 23 studies were included (studies included questionnaire surveys and one interview, extracting barriers and facilitators, and analyzing using qualitative synthesis). Result: TFL indirectly and directly positively affects nurses’ work environment through mediators, including structural empowerment, organizational commitment, and job satisfaction. Nurses perceived that managers’ TFL behavior did not attain excellence in any of the included organizations, highlighting the necessity for additional leadership training to enhance the patient safety culture related to the non-reporting of errors and to mitigate the blame culture within the nursing environment. Conclusion: Bringing more focus to leadership education in nursing can make future nursing leaders more effective, which will cultivate efficient teamwork, a quality nursing work environment, and, ultimately, safe and efficient patient outcomes. This study was not registered.
Keywords: nursing, transformational leadership, work environment, systematic reviewPatient harm caused by errors in healthcare is the leading origin of morbidity and mortality internationally [1]. Researchers are linking adverse patient safety outcomes to a lack of effective leadership, while relational leadership styles, like transformational leadership, continue to be associated with reduced adverse patient outcomes [2,3]. Nursing is dynamic and requires inspiring and engaging leaders and role models. However, the development of nurse leaders is challenging for the nursing profession.
Currently, nurses face a burnout epidemic rooted mainly in the work environment influenced by excessive workloads and a lack of organizational support and leadership [4]. Maben et al. (2022) reported that nurses globally face a heightened vulnerability to mental health issues and suicide, surpassing other occupational groups, while the COVID-19 pandemic has exacerbated the existing challenges in their work environment, further intensifying the already demanding conditions [5]. The engagement in emotional labor within the nursing profession exposes practitioners to a notable susceptibility to experiencing burnout, moral distress, and compassion fatigue. Prior to the onset of the pandemic, the international cadre of nurses was already confronting considerable hurdles, encompassing prolonged duty durations, rotation schedules, inadequate staffing, and periodically arduous situations [5,6,7]. Throughout the pandemic, nurses encountered a range of stress-inducing factors, including managing heightened public expectations and pressure, adapting to new work responsibilities, facing elevated mortality rates, dealing with the infectious nature of COVID-19, experiencing psychosocial stress, confronting the scarcity of personal protective equipment, handling demanding job requirements, and contending with inadequate psychological support [8]. At the same time, scholars have found poor working conditions for nurses and inadequate staffing to predict adverse patient outcomes based on the low-quality nursing job atmosphere and the absence of appropriate leadership styles [9,10].
Safety issues in care, such as adverse events, medication errors, falls, and surgery mistakes, have plagued healthcare systems internationally for decades. Several investigations have acknowledged healthcare environments as high-risk with a lack of safety culture, causing long-delayed discharge, disability, or even death [2,11]. Inherently, the nursing profession and current healthcare climate are chaotic, and a positive safety culture has been proven to come from a creditable and visible leader who supports patient safety behaviors [12]. It is important to recognize that nurses have the highest patient interaction, making nurse leaders central catalysts to positively influencing patient safety culture to reach safer patient outcomes [13,14].
The quality of the nursing work environment is an indicator of nurse satisfaction. A leader who involves staff fosters teamwork, rewards good performance, and encourages motivation can impact the quality of work life [15,16]. The leadership style describes how the leader interacts with others and can be categorized into two main styles: task-oriented and relational [17]. Historically, leadership theories started with the Great Man Theory during the Industrial Revolution with strong hierarchical leader-centric decision making, focusing on command-and-control, productivity, and seeing the organization as linear, operating like a machine [18]. This leadership style model in healthcare is no longer sustainable, as proven by a lack of change and persisting patient safety issues. Researchers have found that healthcare innovation requires nonlinear and emergent social processes that result in improved organizational outcomes [19]. In recent years, the two relational styles, transformational and transactional leadership, have been explored through nursing literature and have become high profile in general healthcare research.
Transformational leadership is composed of four key components. Firstly, “idealized influence” involves the leader behaving as a robust role model toward followers, demonstrating a work ethic and strong values while preaching the organization’s vision, thereby winning the staff’s trust and confidence [20]. The second type of behavior is referred to as “inspirational motivation”. It includes creating a compelling and inspiring vision for the future and communicating it to followers through emotionally charged speeches, vivid imagery, and captivating symbols. This encourages followers to strive to reach this shared vision, thus creating a deeper level of commitment and higher performance [17]. The third type of behavior is called “intellectual stimulation”. Intellectual stimulation encourages followers to think outside the box and consider different approaches to everyday issues, enabling them to devise innovative solutions to these problems [21]. The final category of behaviors is “individualized consideration”, including coaching, helping followers achieve goals, and providing a supportive climate. By carefully listening, leaders can help fulfill those needs [22]. For instance, some followers might require explicit guidance regarding how to get a job done, while others require the provision of needed resources so they can figure out the solution on their own. Nonetheless, TFL’s four behaviors construct a transformational leader if performed consistently and are found to bring respect and admiration by followers [23].
Healthcare systems are globally facing a crisis, with nurse shortage being a perennial issue. Nurses have the highest patient interaction, making nurse leaders central catalysts in positively influencing patient safety culture to reach safer patient outcomes [13]. At the same time, negative nursing work environments cultivate dissatisfied nurses who are likely to suffer from emotional exhaustion or burnout because of ineffective leadership [14]. Amidst these challenges, there is growing recognition of the potential impact of transformational leadership in healthcare settings.
Transformational leadership is characterized by its focus on relationship-building, empowering followers, and emphasizing shared values and vision. This leadership style has been found to positively affect various industries and sectors, including healthcare. However, there remains a gap in knowledge regarding its specific effectiveness in healthcare settings. A comprehensive analysis of the potential benefits of transformational leadership in the healthcare context is warranted. This systematic review aims to address this gap by investigating the effectiveness of transformational leadership and its potential to create better working environments, ultimately leading to improved patient outcomes. We have identified a crucial area of inquiry that has not been thoroughly examined in the existing literature—a systematic review that delves into the relationship between transformational leadership and its effects on both the working environment and patient outcomes. We have identified a single literature review from the preceding decade (2002–2012) that focused on the efficacy of transformational leadership in relation to both work environments and patient outcomes [24]. Considering this, our current investigation is oriented towards delving into scholarly works spanning the subsequent decade (2012–2022), with the intention of comprehensively examining the evolving discourse on this subject matter. By exploring and synthesizing the current body of knowledge on this topic, our study will contribute valuable insights to the field, allowing healthcare organizations to better understand the impact of transformational leadership and make informed decisions regarding their leadership practices.
The significance of this research lies in its potential to shed light on a promising approach to address the pressing challenges faced by healthcare systems—nurse shortage and dissatisfaction—through effective leadership strategies. By providing evidence-based insights, this review seeks to guide healthcare leaders in adopting transformational leadership practices to create a positive work environment for nurses, reducing emotional exhaustion and burnout, and ultimately enhancing patient care and safety.
In conclusion, the dearth of research on the relationship between transformational leadership, work environment, and patient outcomes in healthcare settings highlights the necessity of this review. By examining the effectiveness of transformational leadership and its potential impact on nurses’ well-being and patient outcomes, our study aims to fill this critical gap in knowledge and contribute to the advancement of healthcare leadership practices.
Having delineated the rationale and imperative for conducting this systematic review, our primary aim was to search, retrieve, and critically evaluate all pertinent studies centered around the concept of transformational leadership, with a particular focus on its efficacy in fostering an improved working environment for nurses and influencing patient outcomes comprehensively and systematically.
Our aim was to synthesize and analyze studies, and therefore, we used the PICo framework for studies to determine a research question. PICo is the simplest of the frameworks to use for qualitative questions; it stands for Population, Interest, and Context and can be used to find a range of primary literature. The Population in our study is nurses; the Interest is transformational leadership, working environments, and patient outcomes; and the Context is hospitals. Based on the PICo framework, we formulated our research question as follows: “What is the impact of transformational leadership on staff nurse work environments and patient outcomes?”
To effectively accomplish our aim and investigate our research question, we utilized a systematic review approach following the guidelines outlined in the PRISMA 2020 statement [25]. The PRISMA 2020 checklist is available in Appendix A. In the subsequent subsections, we provide a comprehensive overview of our methodology.
Each of the chosen studies incorporated in this systematic review had to fulfill specific inclusion criteria, as outlined in Table 1 provided below.