Carla Rizzo 1, Flavio Marti 2, Luca Perrozzi 3*, Lucia Mauro 4

  1. Complex Anesthesia, Resuscitation and Intensive Care Unit, IRCCS Hospital Physiotherapy Institutes, Rome
  2. Department of Health Professions AO San Camillo Forlanini, Master’s Degree Course in Nursing and Midwifery Sciences, “Sapienza” University of Rome, San Camillo headquarters
  3. Emergency Acceptance and Specialist Surgery Department, A.O. San Camillo Forlanini, Rome
  4. Department of Surgical Sciences, Elective Operating Block, A.O. San Camillo Forlanini, Rome

*Corresponding Author: Luca Perrozzi, Department of Emergency Acceptance and Specialist Surgery, Azienda Ospedaliera San Camillo Forlanini, C.ne Gianicolense 87, 00159 Rome (Italy). Email: lucaperrozzi@yahoo.it

Cite this article

ABSTRACT

Introduction: Healthcare organisations require optimal leadership to achieve goals and deliver high-quality services. Leadership is the ability to influence employee behaviours and beliefs, and is an essential element of a successful organisation. Improving job satisfaction is a key objective in addressing the challenges related to achieving and maintaining quality standards, ensuring patient satisfaction and staff retention. Similarly, transformational leadership has positive effects on nurses’ job satisfaction and promotes organisational wellbeing in the workplace.

Objective: The purpose of the review is to describe transformational leadership and job satisfaction in the nursing profession through a narrative revision.

Materials and methods: The bibliographic research was carried out between September 2022 – March 2024 by consulting databases such as: PubMed, CINAHL, and PsycInfo with time limits of 12 years and Italian and English language filters. All items deemed relevant have been stored and managed with the Zotero IT platform.

Results: 16 studies were included, including: 1 comparative study, 5 descriptive correlational studies, 1 meta-analysis, 1 systematic review, 4 cross-sectional studies, 2 mixed method studies and 2 unspecified studies. The results of this study are consistent with transformational leadership theory, which highlights the leader’s role in providing employees with supportive work environments that result in higher levels of job satisfaction and efficiency.

Conclusions: The characteristics of a transformative leader such as listening, support, equity and recognition are fundamental to increase nurses’ job satisfaction and to create environments with better quality of care. Healthcare managers must protect the quality of work life of staff, using strategies that can improve the working conditions of nurses.

Keywords: Transformational Leadership; Job Satisfaction; Nurse; Work environment.

INTRODUCTION

Healthcare organisations are social systems in which human resources are the most important factor for the delivery of health care. Such organisations require optimal leadership to achieve goals and deliver high-quality services[1,2]. Leadership is the ability to influence employee attitudes and beliefs and is an essential element of a successful and efficient organisation[3,4]. The current challenges of the health system require the presence of flexible and efficient managers [5] because the complexity of nurses’ tasks requires complex leadership skills[6]. A wide range of studies have described the favourable outcomes of positive leadership, in particular the transformational leadership style[7–9];
Transformational leadership motivates problem-solving and intellectual stimulation by influencing staff engagement in the organisation’s mission. These leaders stimulate nurses to use problem-solving strategies and to take care of the patient autonomously and responsibly[10]. Some studies suggest that transformative leaders have positive effects on the wellbeing and job satisfaction of healthcare workers[4,11]. In addition, transformational leadership transforms nurses’ goals and values for the benefit of the nursing profession [12] and work organisation and promotes team communication and collaboration, the work environment and organisational culture[13].
Work satisfaction, defined as “a pleasant emotional state that derives from the judgment of one’s work or work experience”[14], is extremely important both for nursing managers and for the work well-being of nurses. Improving job satisfaction is a key objective in addressing the challenges related to achieving and maintaining quality standards, ensuring patient satisfaction and staff retention[15,16].
The more satisfied employees are, the more motivated they are to work and the greater the possibility of achieving the objectives, with an increase in productivity and quality. Job satisfaction cannot be ignored if improving work performance is a priority of the organisation[17].
Within the study, the authors described transformational leadership and staff job satisfaction, with the aim of synthesising the evidence that describes these aspects in the nursing profession.
Transformational leadership theorists indicate that leaders use socialised power to elevate and empower subordinates and provide the resources needed to achieve more than they thought possible in their work. Intrinsic motivation strategies support nursing autonomy, competence and relationship with others in the context of a mutually supportive environment to foster social and personal development at the service of the organisation’s vision, mission, values, aims and objectives. In this way, subordinate nursing staff get satisfaction in overcoming work challenges.
Nursing leaders must be proactive in recognising and addressing the job satisfaction needs of direct care nursing staff in order to maintain high quality staff as well as the quality of patient care and healthcare environments[18].

 

Objective of the study

The purpose of the review is to describe transformational leadership and job satisfaction in the nursing profession through a narrative revision of the literature.

MATERIALS AND METHODS

The bibliographic research was carried out from 1 September 2022 to 31 March 2024 by consulting the following databases: PubMed, Cinhal, PsycInfo with time limits of 10 years and Italian and English language filters. The research question was developed following the PICO methodology, as in table 1.

Table 1. Research question identified through the PICO methodology

The following keywords were used: “transformational leadership”, “job satisfaction” and “nurse*”. Within the study, all the articles that dealt with transformational leadership and job satisfaction in the nursing profession with a time limit of 12 years (from January 2012 to March 2024) were included in English and Italian. All articles written in other languages have been excluded.

RESULTS

The bibliographic research, through the research string, produced 223 articles on 3 different databases (PubMed, Cinhal, PsycInfo) (figure 1).

 

Figure 1. “PRISMA Statement” flowchart[19].

 

All items have been managed with the Zotero IT platform. After the duplicates were removed, there were 137 articles. The selection by title and by abstract led to the exclusion of 109 articles. For the subsequent critical analysis, the 28 articles were read and evaluated in their entirety to identify and understand the content. When reading the full texts, 12 articles were discarded because they were not related to the inclusion criteria. A total of 16 studies were evaluated and their analysis resulted in: 1 comparative study, 5 descriptive correlational studies, 1 meta-analysis, 1 systematic review, 4 cross-sectional studies, 2 mixed method studies, 2 unspecified studies (see table 2). Fifteen articles were published in English and one in Italian.

Evaluation of the quality of the studies

The selection and evaluation of the articles took place using the checklists from “JBI Critical Appraisal Tools” [20]. A total of 16 articles were reviewed. To classify the studies according to quality, the overall score was calculated based on the number of “yes” answers. The included studies had at least 6 out of 10 of the items included in the checklists chosen by the authors of this study.

Table 2. Summary of the selected studies

DISCUSSION

The literature considered highlights that the transformational leadership style can positively influence job satisfaction in most of the included studies, regardless of the sample, the country, or the type of study chosen [21–34]. Only two studies do not describe a positive link between the variables analysed[35,36].
The results of this review highlight that the characteristics of a transformative leader – such as listening, support, equity and recognition – are fundamental to increase nurses’ job satisfaction and to create environments with better quality of care.
For example, the results of the systematic review of Specchia [31] and AbuAlRub and Alghamdi [34] emphasise that leaders who adopt a transformative style promote greater job satisfaction among nursing staff than those who have a transactional style. In fact, transformational leadership shows a significant and moderate correlation with job satisfaction (r=0.45, p<0.001), while transactional leadership shows a weak significant relationship with job satisfaction (r = -0.14, p <0.01)[34]. In fact, the strength of transformational leaders is to dedicate time to teaching and coaching nurses, to focus on developing and improving their strengths, and to provide advice for their professional and personal development[31].
These results are consistent with previous studies by Al-Hussami [37] and Bass [38]. These studies support the idea that nurses who worked with leaders who showed transformational leadership styles were more satisfied. In fact, these leaders taught and trained nurses, providing advice for professional development, treating them as individuals, listening to their concerns, and promoting their personal development[39].
Another issue concerns the correlation between transformational leadership, job satisfaction and the intention to leave work. For example, Labrague’s study [26] shows how the transformational leadership of nursing executives influences nurses’ job satisfaction and their intention to leave the profession despite the demographic characteristics (age, sex, sentimental situation, full time). Specifically, it differentiates toxic leadership from transformational leadership. Toxic leadership is significantly correlated with dissatisfaction at work (r = -0.19, p<0.001), absenteeism (r = 0.23, p <0.001), psychological distress (r = 0.09, p<0.05), organisational turnover intention (r = 0.11, p<0.01) and professional turnover intention (r = 0.14, p<0.001). Instead, transformational leadership is significantly related to job satisfaction (r = 0.37, p <0.001), absenteeism (r = -0.13, p<0.001) and the intention of organisational turnover (r = -0.08, p<0.05). It is emphasised how important it is within health facilities to try to instruct nursing executives and managers to develop behaviours that help and support staff, as maintaining a quality work environment greatly affects nurses’ retention and decreases the intention to leave the profession or the nursing turnover.
In contrast, the results of the study by AbuAlRub and Alghamdi [34] indicate that the relationship between the transformational leadership style and the level of intention to stay at work was not statistically significant (r = 0.08, P = 0.14), so the transformational leadership style had no effect on the intention to stay at work.
Even if the results on the intention to leave the profession are mixed, transformational leadership is able to provide supportive work environments that result in higher levels of job satisfaction and effectiveness[39]. In fact, by strengthening solid relationships with staff, transformational leaders understand the needs of nurses, they encourage staff to develop skills and autonomy in order to empower them to act.
The studies by Bohaman [23] and Choi [25] analysed the role that structural empowerment has in the relationship between job satisfaction and the transformational leadership style. Structural empowerment, in line with other previous research, [40–42]influences job satisfaction, organisational commitment[41], work commitment[43], lower levels of burnout and work stress [41] and turnover intentions[41,44]. This is due to the characteristics of the transformational leader, such as the ability to listen, inspire staff and stimulate individual and group skills. We can therefore state from these studies [23,25] that empowerment has a positive influence on job satisfaction.
In the study by Borman and Abrahamson,[24] it emerged that nurses who worked for 5 or less years within the hospital had a statistically positive correlation with transformational and transactional leadership, while nurses who worked for 11 or more years did not have any type of significant relationship with any leadership style. For those who worked for 5 or less years, job satisfaction was mainly related to promotion opportunities, while for nursing staff of 11 or more years it had a stronger correlation for supervision. Therefore, leaders must understand the needs of their employees based on individual differences and their work experience.
The studies by McVicar and Laschinger [35,36] did not find a direct correlation between transformational leadership and job satisfaction. Roberts and Turner [36] highlighted how autonomy and distributive justice positively affect job satisfaction (0.503, P < 0.001; 0.272, p < 0.001). Within the study, the authors emphasise that autonomy represents a characteristic of transformational leadership and distributive justice represents transactional leadership. It follows that, even if a direct relationship between the variables considered has not been found, autonomy represents one of the fundamental characteristics of the transformational leadership style. This implies that an increase in autonomy and distributive justice would increase job satisfaction.
Instead, according to Brewer,[35] transformational leadership was not a significant predictor of job satisfaction. The variables with positive significant coefficients related to job satisfaction were organisational commitment, autonomy, tutor support and promotional opportunities. Considering job satisfaction as a dependent variable, the nurse who goes from a low organisational commitment value to a very high organisational commitment value is 12.6% more likely to be satisfied.
The Barlow meta-analysis [22] showed a very strong relationship between transformational leadership and job satisfaction, since the dimensions of the effects grouped between the studies generated by the estimates of the size of the effect are more powerful and more representative than the individual studies examined. The study shows how transformational leaders stimulate and empower nurses to provide the resources needed to achieve greater results. In fact, staff intrinsic motivation strategies support autonomy, competence and nursing relationships to create a mutually supportive work environment in order to promote social and individual development at the service of the organisational mission, values and objectives. In addition, the results report that the relationship between transformational leadership/job satisfaction has strengthened over time. The subgroup analysis showed that studies in the 21st century have stronger effects than studies in the 20th century. This can be explained by the identification of the Magnet design health and nursing excellence programmes increased especially in the 21st century[22]. Therefore, it is important that today within the hospitals strategies are stipulated to increase nurses’ job satisfaction, evaluating staff satisfaction annually and improving working conditions.
Another result to consider concerns the difference reported in various studies within the Barlow meta-analysis [45–47] between the greater satisfaction detected by nurses in indirect or mixed care (nurse administrators, specialised nurses) compared to staff engaged in direct care (ward nurses). This can be explained by the great shortage of nurses that is being experienced worldwide, which leads to greater workloads, work stress, burnout, intentions to leave the profession and turnovers that strongly affect job satisfaction. This is why nursing leaders are fundamental in order to understand and recognise the needs of their staff, to maintain a high quality of work, as direct care provides essential services for patients.
The article by Morsiani[29], conducted in Italy, analysed, through focus groups, what were the main characteristics for a leader related to job satisfaction:

 

  • Professional recognition. Job satisfaction depends on professional recognition, that is, giving value to the work of a nurse and expressing appreciation for the work of the staff.
  • Equity. Nursing leaders must have the same behaviour and honesty with all staff and be objective about mistakes at work.
  • Be cared for. If a leader supports and listens to their staff, the latter will be more likely to experience job satisfaction. Often the role of nurses, especially in Italy, is not recognised at a social and economic level. The first in the field who must defend the profession are precisely the leaders who must lead the profession to its emancipation, while maintaining relationships with other professionals. In fact, it is not a war between different professions, but only to raise the value of the nursing profession.
  • Support. At a global level, the shortage of nurses has an impact on patient care, since at the same time and with fewer human and material resources it is necessary to achieve the same care result. The leader should not put themselves on a different plane than the nurses, but should be present in the ward and help them in case of need. In addition, being present in the department is an opportunity to check the work of the staff and recognise what the errors may be within the care path and look for strategies to improve it.
  • Listening. Being present also means knowing how to listen, understand the needs of the staff, such as shift scheduling and the difficulties encountered at work.
  • Be appreciated. The nursing manager must promote staff development by seeking to improve nurses, both individually and as a group. Training, feedback, and refresher courses are crucial tools in order to ensure that staff have greater autonomy and responsibility.
  • Team development. Another important issue is teamwork. In this study it emerged how much the staff did not feel part of a work group. Teamwork is fundamental in order to collaborate, to get to where another person cannot, to have common objectives and strategies, and to achieve patient satisfaction.

Therefore, future studies using a more rigorous research approach could be explored, allowing the causal link between the variables considered and the generalisability of the results to be demonstrated.

CONCLUSIONS

The review found that transformational leadership can have a positive influence on nursing job satisfaction levels. Therefore, nursing leadership assumes a fundamental role in influencing the perception that nurses have of their organisation. A leadership style that promotes nurses’ autonomy, support, and empowerment can improve job satisfaction, organisational commitment, and nurses’ intention to remain in their position while reducing emotional exhaustion [6]. This means that transformational leaders, through their stimulating and motivating behaviour, can induce changes in the psychological states of workers within organisations. In addition, some studies have shown how the adoption of the transformational leadership style can indirectly influence job satisfaction through the development and strengthening of nurses’ sense of empowerment[23,25]. Within healthcare organisations, leadership plays a key role in providing effective and efficient care and translates into positive outcomes for professionals, patients and the work environment. It is therefore necessary to identify and fill the current gaps in the skills and competences of nursing leaders through educational activities in institutions, underlining the importance of a two-way communication process and mutual trust between managers and nursing staff. The purpose of the review was to offer an overview of a current topic, as both job satisfaction and transformational leadership are two fundamental issues to create a healthy and efficient work environment. Despite the fact that leadership and job satisfaction have valid and generalisable measurement tools, few studies are able to use these and draw conclusions from the relationship between these variables. For the future, the authors suggest carrying out studies that can correlate transformational leadership and job satisfaction in order to obtain more generalisable results, since these issues are based much more on empirical experience than on robust scientific evidence.

 

Possible funding

This research did not receive any form of funding.

Conflicts of interest

The authors declare that they have no conflicts of interest associated with this study.

 

Limitations of the study

Although the research met the objective of this study, the review has limitations. For example, one of the limitations of narrative review concerns the methodology itself, since while a systematic review has a clear and obligatory methodology a priori, a research protocol is missing in narrative review. Another limit is the bias of interpretation of the results, which can bring out only part of the chosen topic. To confirm what has been described in this review, other studies are needed that can obtain certain, reproducible, and generalisable results. In addition, the results that emerged from the other studies were evaluated by means of self-assessment questionnaires, which can often be associated with response bias.

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