Transformational Nursing Leadership And Effects On Job Satisfaction: An Integrated Literature Review

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

Karen Fugate

University of Central Florida

TRANSFORMATIONAL NURSING LEADERSHIP AND EFFECTS ON 8

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 design
Level VI
A convenience sample of staff RNs working in 6 public hospitals
n = 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 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. / 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 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 design
Level VI
A convenience sample drawn from a population of nurses and nurse managers in a large metropolitan hospital campus
n = 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 America / Evidence review
Level V
7 studies were included in the final evaluation of evidence. All were quantitative in design and used correlational, non-experimental, or cross-sectional designs. / No direct intervention.
The evidence review was conducted to answer the PICO question “In healthcare organizations (P), how does transformational leadership (I) influence staff satisfaction and job burnout (O)?” / 3 studies evaluated leadership style and influence on staff satisfaction (2 were conducted in large acute care 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