International Journal of

Environmental Research
and Public Health

Article
Linking Transformational Leadership with
Nurse-Assessed Adverse Patient Outcomes and the
Quality of Care: Assessing the Role of Job
Satisfaction and Structural Empowerment
Muhammad Asif 1 , Arif Jameel 1 , Abid Hussain 1 , Jinsoo Hwang 2, * and Noman Sahito 3
1 School of Public Affairs, Zijingang Campus, Zhejiang University, Hangzhou 310058, China
2 The College of Hospitality and Tourism Management, Sejong University, 98 Gunja-Dong, Gwanjin-Gu,
Seoul 143-747, Korea
3 Department of City & Regional Planning, Mehran University of Engineering & Technology,
Jamshoro 76062, Pakistan
* Correspondence: jhwang@sejong.ac.kr; Tel.: +82-2-3408-4072




Received: 17 June 2019; Accepted: 3 July 2019; Published: 4 July 2019


Abstract: The purpose of this study was to examine the relationships between transformational
leadership (TL), structural empowerment (SE), job satisfaction (JS), nurse-assessed adverse patient
outcomes (APO), and the quality of care (QOC). The study further investigates the mediating effects
of SE and JS on TL-APO and TL-QOC relationships. A total of 600 nurses working at 17 government
hospitals in Pakistan completed the survey. The hypothesized model was tested using a confirmatory
factor analysis and structural equation modeling. We found a positive relationship between TL, SE,
JS, and QOC but negative relationships between TL and APO, SE and APO, and JS and APO. Our
study further suggests that SE and JS strongly mediate both TL-APO and TL-QOC relationships.

Keywords: transformational leadership; structural empowerment; job satisfaction; nurse-assessed

adverse patient outcomes; quality of care; government hospitals; Pakistan

1. Introduction
Patient outcomes and patient care quality are considered as noteworthy elements for health care
bodies in the world. A lot of research across the world has exhibited that healthcare schemes are
inclined to be faulty, and the danger of adverse patient outcomes (APO) are significant [1,2]. APO is
described as the accidental complications caused by healthcare administration rather than patients’
disease procedures, which ultimately result in lengthy hospital stays, increased death ratios, and
disability [3]. For instance, more than 98,000 patients die and up to one million more are wounded or
injured every year in the USA as a result of avoidable medical errors [2].
Similarly, up to 138,000 hospitalizations occurred during the period from 2014 to 2015 in Canada,
and around 30,000 patients agonized through avoidable damage [4]. In Pakistan, around 500,000
individuals, which mainly includes children and women, die every year due to medical errors
that include incorrect prescriptions, over medicating, self-treatments, and the adversarial results of
medicines [5]. It is also exhibited that a country’s economic cost is also increased due to these APOs,
For example, the cost of these APOs in Canada was projected at 1.1 billion US Dollars for the period
from 2009 to 2010 [6].
Prior research shows that a terrifyingly high ratio of adverse incidents in healthcare institutions is
because of preventable circumstances, some of which are due to nurse-related aspects [7]. For example,
in a study conducted in five countries, Aiken, et al. [8] concluded that poor working conditions for

Int. J. Environ. Res. Public Health 2019, 16, 2381; doi:10.3390/ijerph16132381 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019, 16, 2381 2 of 15

nurses and inadequate staffing were predictors of adverse patient outcomes. Scholars have associated
these outcomes with the low quality of the nursing job atmosphere and the absence of appropriate
leadership styles [7,9]. Previous studies found that deficiencies in hospital care quality are common in
all countries [10,11] and an improvement in the work environment is a low-cost strategy to improve
safety and quality in hospital care and to increase patient satisfaction [12]. In the institutional context,
transformational leadership (TL) is known as a relational leadership that helps healthcare organizations
to overcome APOs [13]. However, only a few types of research has explored the ways that leadership
effects the behavior of the employees and successive implications about the safety consequences of
the patients [14,15]. For example, Houser [16] found that transformational leadership practices were
positively related to staff expertise and negatively related to staff turnover, both of which contributed to
reduced adverse patient outcomes including patient mortality, hospital acquired infections, medication
errors and patient falls. Capuano, et al. [17] added to these findings by showing that transformational
leadership practices were also associated with staff expertise, which in turn decreased the same adverse
patient outcomes. The findings of Paquet, et al. [18] also revealed the indirect effect of leadership on
patient outcomes (decreased medication errors and patient length of stay) through reduced absenteeism.
On the other hand, Lavoie-Tremblay, et al. [19] indicated that transformational leadership practices
potentially lead to high quality of care and weak intention to quit the healthcare facilities. In the
perspective of these studies, the main focus was to determine the ways that TL related to factors that
affect the quality of healthcare and the safety of patient outcomes. Hence, the aim of this research is to
develop a research model that links transformational leadership (TL) to structural empowerment (SE)
and job satisfaction (JS) and then to the occurrence of APOs and the patient’s quality of care (QOC). In
this research, the researchers assessed how TL impacts the patients’ desired QOC and APO through
mediators, SE and JS.
Since TL directly influences workers’ behaviors and achieves the required performance concerning
the expectations of their followers [20], previous research has revealed that TL is a crucial leadership
style that helps make a helpful work atmosphere where the nursing staff is structurally empowered
and highly satisfied to deliver the best patient care [13]. Scholars have recommended that TL should
appear as the most relevant leadership style for current stressed and turbulent healthcare work
environments [21,22]. Adopting TL to resolve these problems may offer an insight into the healthcare
system, therefore leadership may enhance the desired patient outcomes and QOC.

2. Theory and Hypotheses

2.1. Relationship between Transformational Leadership, Job Satisfaction, and Structural Empowerment
TL is a type of relational leadership where the leaders have respect and trust from their followers
and put extra efforts to accomplish institutional objectives [23]. TL has four key components. The first
component is idealized influence, which depicts a leader who acts as a role model for his subordinates,
establishes extraordinary values of conduct, and express organization vision in order to gain employees’
confidence and trust. The second component, inspirational motivation, reveals a leader’s abilities to
express an organizational vision through images, symbols, and signs [23] to motivate their subordinates
to perform in a better way. The third component, intellectual stimulation, indicates the level of a
leader’s capabilities to inquire the issues faced by their subordinates and generate a wide range of
ideas to address these issues and make them available in the decision making process [23]. The final
component, individualized consideration, involves leaders seeking the employees’ differences and
then facilitate them with a mentor for proper guidance, training, and support in order to reduce the
issues and attain their maximum capacity [24].
TL has constantly been associated with worker behaviors in healthcare organizations. Scholars
propose that the four aspects of transformational managers may act as precursors to make structurally
empowering job atmospheres. For example, a transformational leader may encourage nurses using
intellectual stimulation by involving them in the process of making decisions, which promotes rational
Int. J. Environ. Res. Public Health 2019, 16, 2381 3 of 15

thinking and the growth of knowledge, attitudes, and abilities. These types of leaders’ build stimulated
situations for the nursing staff by providing the required assistance, resources, and information at
the workplace. Moreover, TL is linked to the employees’ JS [25], institutional performance, employee
work commitment [26], and followers’ readiness to put in extra efforts to obtain the assigned goals.
McCutcheon, et al. [27] found a significant relationship between TL behaviors and JS among the nurses
in Canadian acute care hospitals.
Transformational leaders develop the patient’s care quality and citizenship behaviors by providing
an appropriate practicing atmosphere. These studies show the significance of TL to make a work
atmosphere that helps and promotes a better practicing environment for nurses to be professional
and enhance the desired outcomes for both the nurses and the patients [28]. By creating progressive
relationships, transformational managers obtain the confidence of their employees and foresee their
requirements by making them structurally empowered in terms of information, professional support,
and resources, which ultimately leads to work satisfaction and enhanced QOC. Based on these
arguments, we made the following predictions.

Hypothesis 1 (H1). TL is positively related to nurses’ JS.

Hypothesis 2 (H2). TL is positively related to SE.

2.2. Relationship between Structural Empowerment, Job Satisfaction, Quality of Care, and Adverse
Patient Outcomes
The SE theory describes how managers or leaders affect the followers’ behaviors in order
to complete their tasks in effective and efficient manners. Transformational leaders can get jobs
completed by their followers by granting them access to four basic organizational factors that include
resources, opportunities, support, and information. Accessibility to resources denotes having the
required stuff, money, stocks, time, and the tools needed to complete the task [29]. Accessibility to
opportunities involves incentives, challenges, job position/status, value, and competency appreciation
that enhance the abilities and skills of the workers. Support accessibility comprises of the directions and
feedback offered by bosses, juniors, managers, and the societal and emotional care from the coworkers.
Lastly, accessibility to information involves having adequate information about the institutional
objectives, the norms, and the policies along with the technical knowledge required to fulfill the job
requirements [29,30].
The basic purpose of every healthcare organization especially in terms of nursing care is to fulfill
the patient’s needs and achieve the desired patient outcomes [31]. Patient outcome studies have
recognized that most of APOs have occurred due to an inappropriate work environment [32] and the
absence of effectual and operative leadership [2,9]. According to Aiken, Clarke, Sloane, Sochalski,
Busse, Clarke, Giovannetti, Hunt, Rafferty and Shamian [8] and Laschinger and Leiter [33], bad
working conditions and a lack of nursing staff are the key factors of APOs, which include rescue
failure medication errors and mortality. This research measured different APOs assessed by nurses that
include patient falls, medication faults, hospital-assimilated diseases, and pressure sores/bedsores. The
nursing-rated quality of healthcare offers the most relevant yet distinctive information about outcomes
of the patient, because the nursing staff is concerned virtually at every stage of the patient’s health
care, which builds their perception and provides valuable information. McHugh and Stimpfel [34]
discovered that nursing-measured QOC was connected with impartial hospital quality indicators, such
as the satisfaction of the patient, flop to rescue, and the death rates, offer that the nursing-assessed
patients’ outcomes and the real ones are interlinked.
The term JS is described as the optimistic individual perception towards his job and job
experiences [35]. It has been linked with worker turnover, service quality and effectiveness, and
patient’s satisfaction [36,37]. Patient’s care is the primary focus for nursing staff, and it is a prerequisite
for nurses to offer good QOC. Also, it effects their JS in return [38–41]. These investigations further
Int. J. Environ. Res. Public Health 2019, 16, 2381 4 of 15

stipulate evidence and support for the importance of nursing skills provided to patients during their
stay in the hospitals with an improved QOC.
Several types of research have recognized the SE concept given by Kanter with diverse nursing
staff populations and backgrounds. SE has been linked to different hospital features, such as higher
nurses’ independence and self-determination, control over resources, and good relationships with
doctors [42,43]. While doing a job in an empowering work-atmosphere, the nursing staff has shared
professional support and the proper resource allocation needed for good quality patient care and
reduced unwanted patient outcomes [42,44]. SE has been considered an essential predictor of
job satisfaction in the healthcare delivery system especially with nursing staff [45,46], nurses’ job
engagement [47], a higher level of confidence, commitment and trust [30], intentions to leave [41], higher
quality healthcare, patient’s preferred outcomes, and a decrease in APOs [48]. Scholars recommend
that nurse-followers practicing under the supervision of transformational leaders can enjoy greater
empowerment, which leads to higher JS and improved QOC outcomes, as a result [33,49]. Due to these
factors, we made the following predictions.

Hypothesis 3 (H3). SE is positively related to nurse-assessed QOC.

Hypothesis 4 (H4). Nurses’ JS is positively related to nurse-assessed QOC.

Hypothesis 5 (H5). SE is negatively related to APO.

Hypothesis 6 (H6). Nurses’ JS is negatively related to APO.

2.3. The Mediating Role of Job Satisfaction and Structural Empowerment

JS is an essential nurse’s outcome that is highly influenced by the quality of the working
atmosphere. Even though numerous studies have shown a greater JS among healthcare personnel,
the existence of a higher level of job dissatisfaction among nurses is also significant [38,50]. The
existing literature demonstrated a strong association between nurses’ JS and the quality of the working
environment [45,51]. Abilities to meet with patients’ needs, professional opportunities, relationships
with coworkers, and a balanced workload are the main work environment factors that influence nurses’
JS in the workplace [28,37]. The nurse’s JS plays a crucial role to encounter the challenges associated
with patient’s satisfaction, nurses’ commitment to their institution, and a better quality of patients’
outcomes [7,46,50].
Previous studies revealed that an effective leadership style can help healthcare organizations
to create a healthy environment in order to achieve the desired nurse-patient outcomes. In this
regard, only limited quantitative research has been conducted that recognizes the direct and indirect
processes that help the leaders to foster changes among their followers and enhance the level of patient
satisfaction [15,27]. Therefore, we developed a theoretical model that illustrates the effects of TL on
nurse-assessed QOC, and APO can be examined through SE and JS.
The perceptions of nurses regarding patients’ QOC improved with the time they spent with
their patients and with their experience and expertise. These nurse-assessed QOC perceptions
influence their job and career status, satisfaction and retention, and develop professional and practical
behaviors [37,41,52]. Logically, these behaviors enhance nurse-assessed QOC and further enable the
nursing staff to express these behaviors in a way that establishes a healthy practicing environment,
which ultimately leads to positive patient outcomes and decreases the possibility of APOs [9,53].
Empowered and satisfied nurses that are highly committed to their jobs [54] also put in extra efforts
towards their work [55] and possessed higher levels of QOC [39,49] Therefore, structurally empowered
nurses are more obedient and loyal with the leaders, top-management, and the organizational policies
and procedures implemented by the administration. These behaviors positively influence patient
outcomes and QOC.
Int. J. Environ. Res. Public Health 2019, 16, 2381 5 of 15

Moreover, SE is also highly associated with the working conditions and the environment, which
allow the nurses to practice professionally. Scholars have found that transformational leaders with the
help of SE revealed that SE enhanced nurses’ autonomy level enables them to be involved in the decision
making practices and provides them with easy access to the required information, resource allocation,
and professional support [42,44,56,57]. According to Manojlovich [58], the positive collaboration
between nurses and doctors can establish a better working environment. These collaborative practices
play an intervening role between a structurally empowered work environment and nurse-assessed
QOC and patient outcomes [49,59]. Based on the above evidence, we propose the following hypotheses.

Hypothesis 7 (H7). SE mediates the negative relationship between TL and APO.

Hypothesis 8 (H8). JS mediates the negative relationship between TL and APO.

Hypothesis 9 (H9). SE mediates the positive relationship between TL and QOC.

Hypothesis 10 (H10). JS mediates the positive relationship between TL and QOC.

3. Materials and Methods

3.1. Sample and Design

A cross-sectional data with a random sampling technique was used to evaluate the hypotheses.
The study was conducted in 17 government hospitals, which included 4 district headquarter hospitals
and 13 tehsil headquarter hospitals situated in the Sargodha division, Punjab province, Pakistan, from
March to April 2019. The data was collected from 600 registered female nurses who have a minimum of
1-year experience and are directly working under head nurses or nurse managers. After the participants’
desirability, the survey questionnaire was distributed to them and their secrecy was also assured.
The questionnaire was divided into two parts. First part referred to the participants’ demographic
profiles that included age, gender, education, experience, and employment status (see Table 1 for more
details). In the second part, participants were asked to rate other factors, which included independent,
dependent and mediating variables.
A total number of 386 participants completed the survey with a response rate of 64.33%. Moreover,
we applied two different tests, which included Harman’s one-factor test and the common latent factor
(CLF), to overcome the possibility of method bias. The total variance explained during these tests is
22.57%, which is less than 50%, so the data is unbiased [60].
Int. J. Environ. Res. Public Health 2019, 16, 2381 6 of 15

Table 1. Demographic Characteristics.

Demographic Characteristics Number (n) %

Gender
Female 386 100
Male 0 0
Age (years)
21–30 267 69.17
31–40 81 20.98
41–50 35 9.07
51–60 3 0.78
Education
Nursing Diploma 53 13.73
Associate Degree 81 20.98
Bachelor 244 63.21
Master 8 2.07
Employment Status
Full time 298 77.20
Part time 88 22.80
Experience (years)
1–5 241 62.44
6–10 87 22.54
11–15 23 5.96
16–20 14 3.63
21–25 10 2.59
26–30 8 2.07
31–35 3 0.78
Note 1: bachelor degree is enough for nurses to work in Pakistan.

3.2. Measures
TL was evaluated using the 7 item scale developed by Carless, et al. [61]. A sample item for TL
included my supervisor communicates a clear and positive vision of the future. The value of α for
the TL scale was 0.97. This study adopted the 12 items’ SE scale proposed by Laschinger et al. [30].
A sample item for SE included the work is challenging for me. The reliability for this scale was 0.98.
JS was evaluated using the 3 item scale proposed by Cammann [62]. A sample item for JS was all in
all, I am satisfied with my job. The reliability (α) for this scale was 0.97. We adopted a 5 item scale to
measure APO that was developed by Sochalski [53]. A sample item for APO was medication errors
occur frequently. The reliability (α) for this scale was 0.93. A 4-item QOC scale was adopted in this
study, which was developed by Aiken, et al. [63].A sample item was how do you evaluate the quality
of the care you offer to patients. The reliability (α) for QOC scale was 0.94. All 31 items used in this
study were measured on a 5-point Likert’s scale.

4. Results

4.1. Data Analysis

In order to analyze the data and the results, we used SPSS and AMOS version 25.0 (IBM, New
York, NY, USA) as statistical tools. For testing mediation effects, structural equation modeling (SEM)
with maximum likelihood estimation was employed [64,65]. We used different fit indices including
chi-square (χ2 ), a comparative fit index (CFI), incremental fit index (IFI), Tucker-Lewis index (TLI),
standardized root mean square residual (SRMR), and root meanssquare error of approximation
(RMSEA) [64,66] to validate the model fit. According to Bentlerand Bonett [67], the values of χ2 /df
should be less than 3 for a model fit, and the values of CFI, IFI, and TLI should be greater than 0.90. [64].
The values of RMSEA and SRMR should not exceed 0.08 [68].
Int. J. Environ. Res. Public Health 2019, 16, 2381 7 of 15

4.2. Demographic Characteristics

As previously discussed, this study contains only female participants (100%) and no male
participants were part of the study. In terms of age, 69.17% of the participants (267 nurses) ranged
from 21–30 years of age, and 0.78% of the participants were 51–60 years of age, which included only
3 nurses. Approximately 63.21% of the study participants (244 nurses) have a bachelors degree in
nursing degree (BScN), and only 8 participants have masters degree (MScN) with a percentage of 2.07.
Among the 386 participants, 77.20% were full-time employees and 22.80% were part-time. A total
number of 241 (62.44%) participants have experience of 1-5 years, and only 3 participants (0.78%) have
31–35 years of experience (see Table 1 for more details).

4.3. Descriptive Statistics

The values of the mean, SD, and correlations of all the studied variables are illustrated in Table 2.
The mean values ranged from 2.91–3.38, and the values of SD ranged from 0.53–0.98. It can be seen in
Table 2 that the correlations among TL, SE, JS, and QOC are positive and significant, but the correlation
of TL, SE, JS, and QOC with APO are significant and negative. Table 2 further demonstrates the
discriminant validity among all the constructs where the values of average variance extracted (AVE)
are greater than the inter-correlational values [69].

Table 2. Descriptive statistics and correlations.

Correlations
n = 386 Mean SD
1 2 3 4 5
1. TL 3.38 0.98 (0.82)
2. SE 2.97 0.53 0.38 ** (0.80)
3. JS 3.13 0.81 0.43 ** 0.48 ** (0.81)
4. QOC 2.80 0.76 0.30 ** 0.41 ** 0.36 ** (0.79)
5. APO 2.91 0.63 −0.26 ** −0.34 ** −0.29 ** −0.24 ** (0.81)
Significance (2-tailed): ** p < 0.01. Square root of AVE is shown in parenthesis (bold) demonstrating discriminant
validity. Note: SD: standard deviation; TL: transformational leadership; SE: structural empowerment; JS: job
satisfaction; QOC: quality of care; APO: adverse patient outcomes; AVE: average variance extracted.

4.4. Measurement Model

The measurement model is illustrated in Table 3, and the factor loadings, Cronbach’s α, the
t-values values of AVE, and the composite reliabilities of all constructs are demonstrated. The alpha
(α) coefficients for TL, SE, JS, APO, and QOC are 0.87, 0.82, 0.81, 0.78, and 0.81 respectively. These
αs are above the recommended value of 0.70 [70]. The standardized factor loadings ranged from
0.72–0.88 for TL, from 0.74–0.85 for SE, from 0.79 0.84 for JS, from 0.73–0.85 for APO, and from 0.74–0.88
for QOC. All factor loadings are greater than 0.50 [70] and contribute significantly. The t-values for
each item of all the studied variables are greater than 1.96 [64,71]. The values of average variance
explained (AVE) for TL, SE, JS, APO, and QOC are 0.67, 0.64, 0.65, 0.66, and 0.63 respectively. These
values provide convergent validity, because all of them are above the recommended value of 0.50 [72].
The composite reliability (CR) for TL, SE, JS, APO, and QOC ranged from 0.82–0.89 and are greater
than the recommended criteria 0.60 [73].
Int. J. Environ. Res. Public Health 2019, 16, 2381 8 of 15

Table 3. Overall measurement model.

Stand. Factor Composite

Construct Cronbach’s α Items S.E. T AVE
Loadings Reliability (CR)
TL 0.87 TL1 0.84 - - 0.67 0.89
TL2 0.85 0.051 16.67
TL3 0.78 0.053 14.72
TL4 0.72 0.050 14.40
TL5 0.83 0.053 15.66
TL6 0.88 0.054 16.30
TL7 0.87 0.054 16.11
SE 0.82 SE1 0.83 - 0.64 0.85
SE2 0.85 0.052 16.35
SE3 0.79 0.051 15.49
SE4 0.81 0.052 15.58
SE5 0.76 0.051 14.90
SE6 0.81 0.051 15.88
SE7 0.83 0.052 15.96
SE8 0.85 0.051 16.67
SE9 0.79 0.050 15.80
SE10 0.78 0.050 15.60
SE11 0.74 0.052 14.23
SE12 0.82 0.051 16.08
JS 0.81 JS1 0.84 - 0.65 0.84
JS2 0.79 0.052 15.19
JS3 0.80 0.051 15.69
APO 0.78 APO1 0.81 - 0.66 0.82
APO2 0.73 0.050 14.60
APO3 0.78 0.051 15.29
APO4 0.85 0.052 16.35
APO5 0.82 0.051 16.08
QOC 0.81 QOC1 0.88 - 0.63 0.83
QOC2 0.83 0.053 15.66
QOC3 0.76 0.051 14.90
QOC4 0.74 0.051 14.51

4.5. Confirmatory Factor Analysis (CFA)

A CFA is the most important statistical test to ascertain the discriminant validity, especially for the
mediation model. Therefore, we evaluated the discriminant validity of all the studied variables, which
included TL, SE, JS, APO, and QOC, using AMOS 25.0 before the hypotheses testing. It can be seen
in Table 4 that the 5-factor model has the best-fitted indices, because the values of χ2 = 479.13, χ2 /df
= 1.67, CFI = 0.98, IFI = 0.98, TLI = 0.97, SRMR = 0.03, and RMSEA = 0.034. We further established
three alternative models that included two 4-factor models, which SE and JS are combined in the first
model, and APO and QOC are combined in the second model, and a 1-factor model, which has all the
items loaded on a single factor. After comparing all the models, we found the 5-factor model was the
best-fitted for this study.

Table 4. Confirmatory Factor Analysis (CFA).

Model χ2 df χ2 /df CFI IFI TLI SRMR RMSEA

5-Factor model 479.13 287 1.67 0.98 0.98 0.97 0.03 0.034
4-Factor model (SE + JS combined) 653.39 302 2.16 0.93 0.93 0.94 0.08 0.059
4-Factor model (APO + QOC combined) 598.27 302 1.98 0.96 0.95 0.90 0.06 0.052
1-Factor model 4557.69 293 15.56 0.49 0.50 0.48 0.27 0.195
Note: SE: structural empowerment; JS: job satisfaction; APO: adverse patient outcomes; QOC: quality of care;
df: degree of freedom; CFI: comparative fit index; IFI: incremental fit index; TLI: Tucker-Lewis index; SRMR:
standardized root-mean-square residual; RMSEA: root-mean-square error of approximation.
 4.6. Hypotheses Testing
index;
For testing
approximation. SRMR: hypotheses, standardized we root-mean-square
performed SEM residual; with RMSEA: root-mean-square estimate.
a maximum-likelihood error of The
4.6. Hypotheses Testing
4.6. For testing
approximation.
correlations
Hypotheses among Testinghypotheses,
all constructs we are performed
illustratedSEM in Table with2,aand maximum-likelihood
the regression coefficients estimate. (β) Theare
4.6. For
correlations
Hypotheses testingamong hypotheses,
Testing all constructs we performed
are illustrated
illustrated in Table 5. H1 for our study is TL is positively related to nurses’ JS. We found support (r SEM in with
Table 2, a andmaximum-likelihood
the regression coefficientsestimate. (β) The
are =
4.6. For testing
correlations
Hypotheses
illustrated in among
TableTestinghypotheses,
5.allH1 constructs
for our we study performed
are illustrated
is TL is SEM in
positively Tablewith 2, aand
related maximum-likelihood
to the regression
nurses’ JS. We coefficients
found estimate.
support (β) The
are
(r =
0.43, Forβ = 0.37, testing t = 7.71, and
hypotheses, p < 0.01)
we for Hypotheses
performed SEM 1 from
with Table
aand 2 and Table
maximum-likelihood 5. H2 is TL is
estimate. positively The
correlations
illustrated
0.43, in
β =J.toEnviron.
0.37, among
Table
tTable
=Res. 5.
7.71, all
H1and constructs
for our
p < 0.01) study are
for2381illustrated
is TL
Hypotheses is in
positively Table
1 from 2,
related to the regression
nurses’ JS. We coefficients
found support (β) are
(r =
relatedInt.
For
correlations SE.among
testing 2 and
Public
hypotheses, Table
Health 5 provide
2019,
we 16,
performed the evidence
SEM withforTable
this
a and 2 and Table
hypothesis
maximum-likelihood (r 5. H2 isβTL
= 0.38, is positively
= 0.41,
estimate. t(β)
= 8.72,
The 9 of 15
illustrated
0.43,
related β =to0.37, in Table
SE. t =
Table 5.2all
7.71, H1and
and
constructs
forp <our
Table 0.01)5study are
for
provide
illustrated
is TL
Hypotheses
the is evidencein1 Table
positively from for
2,
related
Table
this 2 the
toand
hypothesis
regression
nurses’Table JS.
(r 5.
=WeH2 coefficients
0.38,found
is β TL = support
is
0.41, positively
t =
are
(r
8.72, =
and p < 0.01).
correlations inamong H3 5. predicted
allH1 constructs that SE illustrated
are is positively in1related
Table 2,toand nurse-assessed QOC, andsupport we(β) found
illustrated
0.43,
related
and β =<to0.37,
p SE.
0.01).
Table
tTable
=H3 7.71, and
2(rand
predicted
forp <our
Table that5study
0.01) for is
provide
SE
is TL theis evidence
Hypotheses
positively
positively from
related for related
Table
this
to 2tothe
and
hypothesis
nurse-assessed
regression
nurses’Table JS.5.
(r =We H2 coefficients
0.38,
QOC,
found
isβTL and is positively
= 0.41, we tnurses’
are
=found(r =
8.72,
supportive
illustrated
0.43, β = in
0.37, evidence
Table
t = 5.
7.71, H1 and= 0.41,
for p our
< β =
0.01) 0.43,
study for t
is =TL8.96,
Hypotheses is and
positivelyp1 <from0.01) from
related
Table to
2Table
nurses’
and 2 and
Table JS. Table
We
5. H2 5.
found
is H4
TL was
support
is positively (r =
related
and 4.6.<to SE.
Hypotheses Table 2(r and
Testing Table β =5 0.43,
provide the evidence for this hypothesis (r Table
= QOC,
0.38,5.βH4 = 0.41, t =found
8.72,
JS
0.43, is βppositively
supportive
related = to
0.01).
0.37,
SE.
evidence
t =
Table
H3
related
7.71,
predicted
2 and
and
= 0.41,
to p <
Table
that
nurse-assessed
0.01)5
SE is
for
provide
t =positively
8.96,
QOC,
Hypotheses
the and1prelated
and
evidence
< 0.01)
our
from results
for
to nurse-assessed
from
Table
this 2 Table
provided
and
hypothesis
2 and
Table support
(r 5.
= H2
0.38,(r
is =TL
β
and
0.36,
= is was
0.41,
we
β t=nurses’
0.31,
positively
= 8.72, t
andJS is ppositively
supportive < 0.01). evidence H3
related predicted
(r =
to 0.41, that
β =
nurse-assessed 0.43,SE is t = positively
8.96,
QOC, andand p related
<
our 0.01) to nurse-assessed
from
results Table
provided 2 and
support QOC,
Table (r5. = and
H4
0.36, was we
β found
nurses’
= 0.31,
= 6.08,
related
and p and<toForSE.
0.01).p testing
<Table0.01) asand
H3 predicted evident
2hypotheses, Table from
5we
that Table
performed
provide
SE 2 and
the
is= positively SEM Table
evidence with 5.for
related aH5 wasnurse-assessed
this
to SE is negatively
maximum-likelihood
hypothesis (r =Table
0.38,related
estimate.
QOC, β H4 =and toThe
0.41, APO,
we andt
tcorrelations
=found
8.72,
supportive
JS is positively evidence related (r =
to 0.41, β =
nurse-assessed 0.43, t 8.96,
QOC, andand p <
our 0.01) from
results Table
provided 2 and
support (r5. = 0.36, was β =nurses’
0.31,
and=we 6.08,
found
among<and
ppositively apevidence
0.01). < 0.01)
negative
all constructs
H3 asassociation
predictedevident are thatfrom SETable
=between
illustrated in2 Table
SE and
ist =positivelyand Table
APO
2,prelated
and 5.(rH5the towas
= −0.34, SE
β =is−0.32,
regression
nurse-assessed negatively
t =Table
2coefficients−6.53,
QOC, related and
5.(β) and to
pwas
are we<APO,
0.01).
illustrated
found H6t in
and
=supportive
JS is
6.08,
we found and p <
aNurses’ related
0.01)
negative as (revident
= 0.41,
to β
nurse-assessed
from 0.43, Table 8.96,
QOC,
2 and and
and
Table < 5.
our 0.01)
H5 from
resultswas SETable
provided is and
support
negatively (r
related = H4
0.36,
to β =
APO,nurses’
0.31, H6t β =
and
predicted
supportive
JS
=we
Table
isfound
6.08, positively
and
5.
p
H1related
evidence
< 0.01)
forJSour
as(rassociation
is=tonegatively
study
0.41,
evident
is
βfrom
nurse-assessed
between
TLrelated
= 0.43, Table
SE
QOC,
2
to and
ist positively
= 8.96, and
APO.
andand
APO
pA
related
Table <our (r =to−0.34,
negative
0.01)
5. H5 from
resultswas
β = JS.
relation
nurses’Table
provided
SE is
−0.32, can
2 We
and
negatively
tfound
=be−6.53,
Table
support found 5.and
support
(r
related =H4 in was
0.36,
to
pTable
<(r0.01).
β =0.31,
20.43,
nurses’
=
APO,
and
and t
JS=
predicted
Table
is
6.08,0.37,5and
positively t aNurses’
where =pnegative
7.71,
< r = and
related
0.01)
JSassociation
−0.24,
as
ispto<negatively
βnurse-assessed
evident = −0.29,
0.01) for
from
betweenrelated
tHypotheses
=Table
−6.04, SE
QOC,
2
to and
and
and
APO.
and
APO
1pTable
from our
(r = −0.34,
A negative
< 0.01. Tables
5. results
H5 was
β =5.−0.32,
relation
2 provided
and
SE is H2can ist TL
=be−6.53,
support
negatively
found
is and
positively
(r
related= in pTable
0.36,to
< 0.01).
β related
=
APO,
2 and
0.31,
H6
and to SE.
t
we found
predicted aNurses’
negative JS association
ismediation
negatively between
t related SE to and
APO. APO A (r = −0.34,relation
negative β = −0.32, t =be−6.53, and pTable
< 0.01). H6
Table
=predicted
we 6.08, The
found
5 where
Tables
and results
p2negative
<and
aNurses’
r =of
0.01) 5−0.24,
the
provide
as β =the
evident
association
−0.29,evidence
from between
= −6.04,
effects
Table using
for
2SE and
this
andand
phypothesis
SEM
Table< 0.01.
APO are shown
5.negative
(rH5 (r =in
was
= −0.34, βFigure
0.38,
SE β =can
=is−0.32, 1.0.41,
negatively tThe tfound
=
path
=be−6.53, 8.72,
related from
and
inand
to <TL
pTable p
APO, <to20.01).
0.01).
and
SE
andH6 is H3
Table 5
The where
results r = of JS
−0.24,
the is negatively
β =
mediation −0.29, t related
=
effects−6.04, to
using and APO.p
SEM < A
0.01.
are shown relation
in Figure can
1. The found
path fromin TL to 2 and
SE
we positive
predicted
Table
predicted
found5 where
and
aNurses’significant
that JS
negativer =of−0.24,
(β
SEassociation = 0.57;between
isismediation
positively
negatively
β ==−0.29,
p related
< 0.01),SE
t related
= 0.01),
−6.04,
whereas
to
toand
and APO.pAPO
the
nurse-assessed
A
< 0.01. (r path
= −0.34,
negative from
QOC, β SE=and
relation to we
−0.32, APO
can =be is
t found significantly
−6.53,
foundsupportive
and inpTable negative
< 0.01). 2SEH6is (r
evidence
and
positive The
(β = =−0.29 results
and significant the (β 0.57; effects
p < using
whereas SEM are
the shown
path fromin Figure
SE to 1.
APO The is path from
significantly TL to
negative pis<
predicted
Table 50.41, and β =pr 0.43,
Nurses’
where =<of−0.24,
0.01),
JS t =negatively
is and
β8.96, theand
==−0.29, path p=<−6.04,
from
trelated 0.01)to SEand topQOC
from
APO. <Tables
Aare
0.01. is also
negative2 and positive
5. H4 and
relation was can significant
nurses’
be found JS is (β =Table
0.39 and
inpositively 2 SE
andrelated
positive
(β = to The
−0.29 results
and significant
andother the mediation
(β 0.57; peffects
< 0.01), using
whereas SEM the shown
path from in Figure
SE to 1.
APO The is path from
significantly TL to
negative is
0.01).
Table
positive 5On
The wherethe
nurse-assessed
results
and rp=<of
significant
0.01),
hand,
−0.24,
the βand
QOC,
(β
the the
andpath
path
==−0.29,
mediation 0.57; p
from
tour from
=< −6.04,
effects TL
results
0.01),
SE
to
and
using JStopisQOC
provided
whereas SEM 0.01.
are
the
issupport
<significantly also positive
shown
path
positive
from
= 0.36,
(r Figure
in SE
and
to
(β1.
APO
significant
=β = 0.31,
0.43
Theis
and
path tp= (β
from
significantly
= 0.39
< 6.08,
0.01), TL and and
whereas
to p p<is<0.01)
SE
negative
(β
the = path
0.01). −0.29
On andother
the
from pJS<to 0.01),
hand,
APO andthe the
path path
is=significant from from TL
but SE
to JStoisQOC
negative inisnature
significantly also positive
positive
(β and(βand=significant
0.43 and pwe(β<and= 0.39
0.01), and
whereas pto <
positive
(β =
as
The
−0.29
evident
results
and and
from
of
significant
p < the
0.01),
Tables
mediation
(β
and
20.57;
the
andeffects
path
5.< 0.01),
pfrom H5
from
was
using SE
whereas
SE SEM
to
is
QOC
negatively
are
the is shown
path
also fromin=Figure
related
positive
−0.32
SE toto
and 1.APO,
APO Thepis<path
significant
0.01),
and from
significantly
(β =
found thenegative
TL
0.39 topath
aSE
and
negative
p is<
0.01).
the On
path the
from other JS to APOhand, the path
is= significant TL to JS is significantly positive (β = 0.43 and p < 0.01), whereas
QOC
positive
(β is andsignificantly
association
=path
−0.29 and pJSbetween
significant
<to 0.01), positive
(β
andSE and (βpath
0.57;
the =p <0.23
APO (rbut
0.01),
from and negative
= whereas
−0.34,
SE β=
p <to0.01).
QOC
in−0.32,
the Itisnature
can
alsobe
path =(β
tfromseen=SE
−6.53,
positive
−0.32
intoand
and
and
Figure
APO p <pis10.01).
<significantly
0.01),
that both
H6 and the
direct
=predicted
path
paths
negative to
Nurses’
0.01).
the
QOC On
is the
from other
significantly hand,
APO positivethe path
is significant
(β = from
0.23 TL
but
and to JS< is
negative
p significantly
0.01). in It nature
can be positive
(β
seen= −0.32 in (β =significant
and
Figure 0.43
p 1< and
0.01),
that
(β
pboth<and0.01),0.39
direct
and
thewhereas
pathpaths
pto <
(β from
=
0.01). JS TL
−0.29
On is to
and APO
negatively
the other p < (β =
0.01),
hand, −0.09
related and the and
to
the
path p
APO.
path > 0.05)
A
from and
negative
SE TL
to QOCto QOC
relation is also(β
can = 0.13
be found
positive and and p
in > 0.05)
Tables
significant are
2 and insignificant
(β 5
= where
0.39 and r =
and
p −0.24,
<
the
QOC
from path from
is significantly
TL to APO JS to (β APO
=positive
−0.09 and (β =from
is significant >0.23
TL
but
and to pJS
negative
<TLis significantly
to in
0.01). Itnature
can (βbe =(β
positive
seen= −0.32 (βand
in7–10. = 0.43
Figure and
p 1< that
0.01), p <and
arepboth
0.01), thewhereas
direct pathpaths to
confirm
0.01).
the βOn
path = −0.29,
full
the
from other t =to
mediation.
JS −6.04,
hand,
APO This
and
the
is p <pfrom
evidence
path
significant0.01. 0.05)proves
TL
but
and
to JS mediation
is
negative
QOC
significantly
in nature
0.13
Hypotheses
positive
(β =
and
−0.32 (βp =>0.43
and
0.05)
p <and
0.01),
insignificant
< 0.01),
and the whereas
path
and
to
QOC
from
confirm is significantly
TL to APO
full mediation. (β =positive
−0.09 This and (β p= >0.23
evidence 0.05) andand
proves p <TL 0.01).
to QOC
mediation It can (βbe seenand
= 0.13
Hypotheses in7–10.
Figure
p > 0.05) 1 that
are both direct paths
insignificant and
the
QOC
from path is
TL fullfrom JS
significantly
to APO to APO positive
(β = −0.09 is significant
(β = 0.23 butand negative
p < 0.01). in nature
It can be (β =
seen −0.32in and
Figure p <
1 0.01),
that and
both the
direct path paths to
confirm mediation. Thisand Table
p > 0.05)
evidence 5. β 5.
and TL
proves
coefficients
β coefficients
to QOCHypotheses
mediation
for testing
forcan
(β = 0.13 and7–10.
hypotheses
testing hypotheses 1–6.
p > 0.05) are insignificant and
1–6.1 that both direct paths
QOCfrom is
confirm TLsignificantly
to APO
full mediation. (β =positive
−0.09 Thisand (β p=Table
evidence >0.230.05) and and
proves p <TL 0.01).
to QOC
mediation It (βbe= seen
0.13 and
Hypotheses in 7–10.
Figure
p > 0.05) are insignificant and
Table 5. β coefficients for testing hypotheses 1–6.
from
confirm TL to fullAPO mediation. (β = Path−0.09
Path This and p >Standardized
evidence 0.05) and TL
proves
Standardized to S.E.
mediation
β
β QOC S.E. (βT= 0.13
Hypotheses
T and7–10.
p-value p > Significance
p-value 0.05) are insignificant and
Significance
Table 5. β coefficients for testing hypotheses 1–6.
confirm full mediation. Path This Tableevidence proves mediation
Standardized
5. β coefficients β forS.E. testing Hypotheses
T
hypotheses p-value 7–10.
1–6. Significance
TL JS 0.37
0.37 0.048 7.717.71 < 0.01 <0.01 (**)
0.048 (**)
Path TableStandardized
5. β coefficients β forS.E.testing T p-value
hypotheses 1–6. Significance
TL SE
JS 0.41
0.37 0.047 7.71
0.048 8.72 < 0.01 <0.01 (**) (**)
TL PathSE Table Standardized0.41
5. β coefficients β for0.047
S.E.
testing 8.72
T < 0.01
p-value (**)
1–6. Significance
SE
TL QOC
JS 0.43
0.37 0.048 hypotheses
0.048 7.718.96 < 0.01 <0.01 (**) (**)
TL PathSE 0.41
Standardized β 0.047S.E. 8.72
T < 0.01
p-value (**)
Significance
SE
JS
TL QOC
JS 0.43
0.31
0.37 0.048
0.0480.051 7.71 0.01 <0.01 (**)
8.966.08 << 0.01 (**) (**)
TL PathSE 0.41
Standardized β S.E. 0.047 8.72
T < 0.01 Significance
p-value (**)
SE
TL QOC
APO
JS 0.43
−0.32
0.37 8.96
0.049 7.71
0.048 −6.53< 0.01 <0.01 (**) (**)
JS
TL QOC
SE 0.31
0.41 0.051
0.047 6.08
8.72 << 0.01
0.01 (**)
(**)
SE
TLJS QOC
APO
JS 0.43
−0.29
0.37 0.048
0.048 8.96
0.048 7.71 −6.04< 0.01 <0.01 (**)
<0.01 (**) (**)
JS
TL QOC
SE 0.31
0.41 0.051
0.047 6.08
8.72 << 0.01 (**)
SE
SE
Note: TL:
APO
QOC −0.32
0.43 0.049
0.048 −6.53
8.96 < 0.01
0.01 (**)
(**)
JStransformational
TL QOC leadership;
SE JS: job satisfaction;
0.31
0.41 0.051 SE:8.72
0.047 structural
6.08 empowerment;
<<0.01
0.01 QOC: quality of care; APO:
(**)
(**)
SE
adverse patient APO S.E.: standard
QOC
outcomes; −0.32
0.43 0.049 −6.53
0.048 8.96 < 0.01 (**)
JS
JS APO
QOC 0.31error.
−0.29 0.048 −6.04
0.051 6.08 << 0.01
0.01 (**)
(**)
SE
SE APO
QOC −0.32
0.43 0.049 −6.53
0.048 8.96 <<0.01
0.01 (**)
(**)
JS APO
QOC −0.29
0.31 0.048 −6.04
0.051 6.08 < 0.01 (**)
SE of the
The results APO mediation −0.32 using0.049
effects SEM −6.53
are shown < 0.01
in Figure 1.(**)
The path from TL to SE is
JS
JS APO
QOC −0.29
0.31 0.048 −6.04
0.051 6.08 <<0.01
0.01 (**)
(**)
SE APO −0.32 0.049 −6.53 < 0.01 (**)
positive and significant (β = 0.57; p < 0.01), whereas the path from SE to APO is significantly negative
JS APO −0.29 0.048 −6.04 < 0.01 (**)
SE APO −0.32 0.049 −6.53 < 0.01 (**)
(β = −0.29 and
JS p < 0.01),
APO and the path
−0.29 from SE 0.048
to QOC −6.04
is also< 0.01
positive and (**)significant (β = 0.39 and
JS APO −0.29 0.048 −6.04 < 0.01 (**)
p < 0.01). On the other hand, the path from TL to JS is significantly positive (β = 0.43 and p < 0.01),
whereas the path from JS to APO is significant but negative in nature (β = −0.32 and p < 0.01), and the
path toInt.
QOC is significantly
J. Environ. positive
Res. Public Health 2019, 16, x (β = 0.23 and p < 0.01). It can be seen in Figure91ofthat 14 both direct
paths from TL to APO (β = −0.09 and p > 0.05) and TL to QOC (β = 0.13 and p > 0.05) are insignificant
Note: TL: transformational leadership; JS: job satisfaction; SE: structural empowerment; QOC: quality
and confirm full mediation. This evidence proves mediation Hypotheses 7–10.
of care; APO: adverse patient outcomes; S.E.: standard error.

Figure 1. The
Figure results
1. The resultsof
of the structural
the structural equation
equation modeling
modeling (SEM)
(SEM) for for mediation
mediation effects. effects.

5. Discussion and Implication

Decent work, availability of trained staff, and healthy work conditions in the health sector are
the fundamental subject to ensuring effective and resilient health systems worldwide. The health
sector is essentially about people; without health workers there can be no health care. To address
health workforce shortages effectively, investments in the health workforce have to extend beyond
Int. J. Environ. Res. Public Health 2019, 16, 2381 10 of 15

5. Discussion and Implication

Decent work, availability of trained staff, and healthy work conditions in the health sector are
the fundamental subject to ensuring effective and resilient health systems worldwide. The health
sector is essentially about people; without health workers there can be no health care. To address
health workforce shortages effectively, investments in the health workforce have to extend beyond
increasing numbers of workers. More employment opportunities in the health sector are needed and
those have to be accompanied by measures to provide decent employment and conditions of work in
order to attract and retain competent health workers. The global context of the health sector has in
recent years been marked by important initiatives for strengthening health systems and the health
workforce. A common feature of these initiatives is the call for transformative action, and changing
mindsets to seize the opportunities at hand and address the immense challenges ahead [74].
In this context, the main aim of this research was to explore the influence of TL on nurse-assessed
APO and QOC through the mediating effects of SE and JS. The key finding of our study was to test
the significant mediating mechanism of SE and JS on the relationship between TL and both APO
and QOC. Though TL plays a vital role in providing nurses an empowered working environment to
improve patient outcomes [14], limited research has been conducted to test the influence of TL on
SE. Prior research revealed the association between TL and empowerment with the perspective of a
psychological conceptualization [75,76].
The results of our study indicate that nursing leaders who exhibit transformational behavior
significantly predict the desired patient’s outcomes by reducing the possibility of adverse patient
outcomes (APOs) and increase quality of care (QOC) through the intervening influence of structural
empowerment (SE) and job satisfaction (JS). To be consistent with previous research, our study provides
positive results since adopting the effective leadership style and intervening variables for improving
patient outcomes face some complications. For example, Higgins [28] discovered a negative association
between nurse transformational managers and APOs through the intervention of organizational
citizenship behavior (OCB). In another study, the authors exposed a significant association between
authentic leadership (AL) and reduced nurse-assessed APOs using trust in the leader as a mediator [77].
In our study, the perception of the nurses regarding their leaders was highly transformational.
Transformational leaders express a higher level of expectations towards their subordinates and
motivate them to exert extra efforts to achieve the organizational vision. This will also increase their
level of commitment [24,78]. Transformational leaders also have the abilities of charismatic leadership,
which enables them to inspire their followers to work beyond the expectations. To become successful,
these leaders clearly communicate the organizational mission to the employees, provide them a
clear direction and support, link their work with organizational goals, and influence their level of
commitment in a positive way.
In the healthcare sector, transformational leaders seek out the needs of the nurses and establish a
strong relationship with them as a mentor or coach, listen to their problems, and promote a healthy
work environment for continuous development [21]. When transformational leaders take an interest in
nursing development and empower them to utilize their full potential, nurses feel more self-confidence
and work engagement, which ultimately leads to enhanced patients’ QOC.
Our findings are consistent with previous research that TL may affect the occurrence of adverse
events, since transformational leaders believe in evidence-based work and influence employees to
offer innovative ideas to solve the problems [21,79]. This may increase the nurses’ level of satisfaction
and empowerment and make nurses responsible to take better care of patients with fewer medical
errors. In addition, the results of the present study revealed that accessibility to information, the
availability of resources, and the decision-making participation make the nurses more satisfied and
trustworthy. The strong relationships between TL, SE, and JS signify that improved healthy work
conditions and environment could be the most important element to improve QOC and decrease
APO and job effectiveness. By establishing deep relationships, transformational leaders recognize and
foresee the basic necessities of their nurses and make significant efforts to fulfill their needs and allocate
Int. J. Environ. Res. Public Health 2019, 16, 2381 11 of 15

proper resources to encourage a sense of empowerment and autonomy, which results in improved
desired patient outcomes and satisfaction.

6. Limitations
This study also exhibits some limitations. First, this research is based on a cross-sectional nature,
which restricts the interpretation of the evidence-based causal relationships and theoretical foundations
among the studied variables [80]. A longitudinal study should be conducted in the future to examine
the leaders’ TL and its impact on patient satisfaction, nurses’ outcomes, and the work environment.
Second, our study focused on only two mediators (SE and JS), and future research should opt to use
other intervening variables, such as safety climate, commitment, and burnout, to comprehensively
understand the influence of TL on healthcare outcomes. Third, we recruited only female nurse
participants [81,82]. Future research should include male nurses as well. Fourth, our study used
self-reported instruments, which may cause a response bias [83]. We used Herman’s one-factor and
CLF techniques to test the possibility of this biasness, in future studies; it is recommended to keep
it in mind. Finally, our study sample consisted of female nurses who were working in government
hospitals, and future studies should incorporate both public and private hospitals with a wider area.

7. Conclusions
The results of the present study demonstrated the significant role that transformational leadership
played to enhance the working conditions and atmosphere, which allows the nurses to establish good
relations with patients and improve quality of care and patient satisfaction. Our findings, empirically
contribute to the existing literature by establishing a strong and evidence-based relationship between
transformational leadership and nurse-assessed quality of care and adverse patient outcomes. Second,
we found structural empowerment and job satisfaction as the potential mediators for these relationships.
Our findings further suggest that transformational leadership is a vital indicator that can help the
healthcare organizations to improve quality of care, nurses’ job satisfaction, and reduce adverse
patient outcomes. To overcome the occurrence of adverse events in healthcare organizations, it is
recommended that top management should develop transformational leadership behaviors among
nurse managers/leaders and provide such environments empowerment and autonomy in order to
support their follower nurses. This will better lead to the desired outcomes and improve quality of care.

Author Contributions: Conceptualization: M.A.; Methodology: M.A., A.J. and N.S.; Validation: J.H.; Formal
Analysis: M.A.; Investigation: M.A. A.J. and A.H.; Resources: J.H.; Data Curation: J.H. and N.S.; Writing—Original
Draft Preparation: M.A.; Writing—Review and Editing: M.A., A.J., A.H., N.S. and J.H.; Supervision: J.H.; Funding
Acquisition: J.H.
Funding: The study receives no external funding.
Conflicts of Interest: The authors declare no conflict of interest.

Abbreviations
TL transformational leadership
SE structural empowerment
JS job satisfaction
APO adverse patient outcomes
QOC quality of care

References
1. De Vries, E.N.; Ramrattan, M.A.; Smorenburg, S.M.; Gouma, D.J.; Boermeester, M.A. The incidence and
nature of in-hospital adverse events: A systematic review. BMJ Qual. Saf. 2008, 17, 216–223. [CrossRef]
[PubMed]
2. Kohn, L.T.; Corrigan, J.; Donaldson, M.S. To Err is Human: Building a Safer Health System; National Academy
Press: Washington, DC, USA, 2000; Volume 6.
Int. J. Environ. Res. Public Health 2019, 16, 2381 12 of 15

3. Baker, G.R.; Norton, P.G.; Flintoft, V.; Blais, R.; Brown, A.; Cox, J.; Etchells, E.; Ghali, W.A.; Hébert, P.;
Majumdar, S.R. The Canadian Adverse Events Study: The incidence of adverse events among hospital
patients in Canada. Can. Med. Assoc. J. 2004, 170, 1678–1686. [CrossRef]
4. CIHI, I. Measuring Patient Harm in Canadian Hospitals. What Can be Done to Improve Patient Safety; CIHI:
Ottawa, ON, Canada, 2016.
5. Dawn. Medication Errors Cause Half a Million Deaths in Pakistan, Say Pharmacists. Available online:
https://www.dawn.com/news/1362951 (accessed on 26 May 2019).
6. Etchells, E.; Mittmann, N.; Koo, M.; Baker, M.; Krahn, M.; Shojania, K. The Economics of Patient Safety in Acute
Care; Canadian Patient Safety Institute: Ottawa, ON, Canada, 2012.
7. Aiken, L.H.; Clarke, S.P.; Sloane, D.M.; Sochalski, J.; Silber, J.H. Hospital nurse staffing and patient mortality,
nurse burnout, and job dissatisfaction. Jama 2002, 288, 1987–1993. [CrossRef] [PubMed]
8. Aiken, L.H.; Clarke, S.P.; Sloane, D.M.; Sochalski, J.A.; Busse, R.; Clarke, H.; Giovannetti, P.; Hunt, J.;
Rafferty, A.M.; Shamian, J. Nurses’ reports on hospital care in five countries. Health Aff. 2001, 20, 43–53.
[CrossRef] [PubMed]
9. Page, A. Keeping Patients Safe: Transforming the Work Environment of Nurses; National Academies Press:
Washington, DC, USA, 2004.
10. Aiken, L.H.; Sermeus, W.; Van den Heede, K.; Sloane, D.M.; Busse, R.; McKee, M.; Bruyneel, L.; Rafferty, A.M.;
Griffiths, P.; Moreno-Casbas, M.T. Patient safety, satisfaction, and quality of hospital care: Cross sectional
surveys of nurses and patients in 12 countries in Europe and the United States. BMJ 2012, 344, e1717.
[CrossRef] [PubMed]
11. Hussain, A.; Asif, M.; Jameel, A.; Hwang, J. Measuring OPD Patient Satisfaction with Different Service
Delivery Aspects at Public Hospitals in Pakistan. Int. J. Environ. Res. Public Health 2019, 16, 2340. [CrossRef]
12. Aiken, L.H.; Sloane, D.M.; Bruyneel, L.; Van den Heede, K.; Griffiths, P.; Busse, R.; Diomidous, M.; Kinnunen, J.;
Kózka, M.; Lesaffre, E. Nurse staffing and education and hospital mortality in nine European countries: A
retrospective observational study. Lancet 2014, 383, 1824–1830. [CrossRef]
13. Cummings, G.G.; MacGregor, T.; Davey, M.; Lee, H.; Wong, C.A.; Lo, E.; Muise, M.; Stafford, E. Leadership
styles and outcome patterns for the nursing workforce and work environment: A systematic review. Int. J.
Nurs. Stud. 2010, 47, 363–385. [CrossRef]
14. Wong, C.A.; Laschinger, H.K. Authentic leadership, performance, and job satisfaction: The mediating role of
empowerment. J. Adv. Nurs. 2013, 69, 947–959. [CrossRef]
15. Wong, C.A.; Cummings, G.G.; Ducharme, L. The relationship between nursing leadership and patient
outcomes: A systematic review update. J. Nurs. Manag. 2013, 21, 709–724. [CrossRef]
16. Houser, J. A model for evaluating the context of nursing care delivery. J. Nurs. Adm. 2003, 33, 39–47.
[CrossRef] [PubMed]
17. Capuano, T.; Bokovoy, J.; Hitchings, K.; Houser, J. Use of a validated model to evaluate the impact of the
work environment on outcomes at a magnet hospital. Health Care Manag. Rev. 2005, 30, 229–236. [CrossRef]
18. Paquet, M.; Courcy, F.; Lavoie-Tremblay, M.; Gagnon, S.; Maillet, S. Psychosocial work environment and
prediction of quality of care indicators in one Canadian health center. Worldviews Evid. Based Nurs. 2013,
10, 82–94. [CrossRef] [PubMed]
19. Lavoie-Tremblay, M.; Fernet, C.; Lavigne, G.L.; Austin, S. Transformational and abusive leadership practices:
Impacts on novice nurses, quality of care and intention to leave. J. Adv. Nurs. 2016, 72, 582–592. [CrossRef]
[PubMed]
20. Bass, B.M.; Avolio, B.J. Transformational Leadership And Organizational Culture. Int. J. Public Adm. 1994,
17, 541–554. [CrossRef]
21. Gabel, S. Transformational leadership and healthcare. Med. Sci. Educ. 2013, 23, 55–60. [CrossRef]
22. Enwereuzor, I.K.; Ugwu, L.I.; Eze, O.A. How Transformational Leadership Influences Work Engagement
Among Nurses: Does Person–Job Fit Matter? West. J. Nurs. Res. 2018, 40, 346–366. [CrossRef] [PubMed]
23. Bass, B.M. Leadership and Performance beyond Expectations; Collier Macmillan: Cambridge, UK, 1985.
24. Avolio, B.J.; Bass, B.M.; Jung, D.I. Re-examining the components of transformational and transactional
leadership using the Multifactor Leadership. J. Occup. Organ. Psychol. 1999, 72, 441–462. [CrossRef]
25. Walumbwa, F.O.; Orwa, B.; Wang, P.; Lawler, J.J. Transformational leadership, organizational commitment,
and job satisfaction: A comparative study of Kenyan and US financial firms. Hum. Resour. Dev. Q. 2005, 16,
235–256. [CrossRef]
Int. J. Environ. Res. Public Health 2019, 16, 2381 13 of 15

26. Zhu, W.; Avolio, B.J.; Walumbwa, F.O. Moderating role of follower characteristics with transformational
leadership and follower work engagement. Group Organ. Manag. 2009, 34, 590–619. [CrossRef]
27. McCutcheon, A.S.; Doran, D.; Evans, M.; Hall, L.; Pringle, D. Effects of leadership and span of control on
nurses’ job satisfaction and patient satisfaction. Nurs. Leadersh. 2009, 22, 48–67. [CrossRef]
28. Higgins, E.A. The Influence of Nurse Manager Transformational Leadership on Nurse and Patient Outcomes:
Mediating Effects of Supportive Practice Environments, Organizational Citizenship Behaviours, Patient
Safety Culture and Nurse Job Satisfaction. Ph.D. Thesis, University of Western Ontario, London, ON,
Canada, 2015.
29. Kanter, R.M. Men and Women of the Corporation; Basic Books: New York, NY, USA, 1993.
30. Laschinger, H.K.S.; Finegan, J.; Shamian, J.; Wilk, P. Impact of structural and psychological empowerment on
job strain in nursing work settings: Expanding Kanter’s model. J. Nurs. Adm. 2001, 31, 260–272. [CrossRef]
[PubMed]
31. WHO (World Health Organization). World Alliance for Patient Safety Forward Program; WHO: Geneva,
Switzerland, 2005.
32. Aiken, L.H.; Sloane, D.M.; Bruyneel, L.; Van den Heede, K.; Sermeus, W.; Consortium, R.C. Nurses’ reports
of working conditions and hospital quality of care in 12 countries in Europe. Int. J. Nurs. Stud. 2013, 50,
143–153. [CrossRef] [PubMed]
33. Laschinger, H.K.S.; Leiter, M.P. The impact of nursing work environments on patient safety outcomes:
The mediating role of burnout engagement. J. Nurs. Adm. 2006, 36, 259–267. [CrossRef]
34. McHugh, M.D.; Stimpfel, A.W. Nurse reported quality of care: A measure of hospital quality. Res. Nurs.
Health 2012, 35, 566–575. [CrossRef] [PubMed]
35. Best, M.F.; Thurston, N.E. Measuring nurse job satisfaction. J. Nurs. Adm. 2004, 34, 283–290. [CrossRef]
36. Brewer, C.S.; Kovner, C.T.; Greene, W.; Tukov-Shuser, M.; Djukic, M. Predictors of actual turnover in a
national sample of newly licensed registered nurses employed in hospitals. J. Adv. Nurs. 2012, 68, 521–538.
[CrossRef]
37. Laschinger, H.K.S.; Fida, R. Linking nurses’ perceptions of patient care quality to job satisfaction: The role of
authentic leadership and empowering professional practice environments. J. Nurs. Adm. 2015, 45, 276–283.
[CrossRef]
38. Lu, H.; Barriball, K.L.; Zhang, X.; While, A.E. Job satisfaction among hospital nurses revisited: A systematic
review. Int. J. Nurs. Stud. 2012, 49, 1017–1038. [CrossRef]
39. Chang, W.Y.; Ma, J.C.; Chiu, H.T.; Lin, K.C.; Lee, P.H. Job satisfaction and perceptions of quality of patient
care, collaboration and teamwork in acute care hospitals. J. Adv. Nurs. 2009, 65, 1946–1955. [CrossRef]
40. Kalisch, B.J.; Tschannen, D.; Lee, K.H. Do staffing levels predict missed nursing care? Int. J. Qual. Health Care
2011, 23, 302–308. [CrossRef] [PubMed]
41. Laschinger, H.K.S. Job and career satisfaction and turnover intentions of newly graduated nurses. J. Nurs.
Manag. 2012, 20, 472–484. [CrossRef] [PubMed]
42. Laschinger, H.K.S.; Almost, J.; Tuer-Hodes, D. Workplace empowerment and magnet hospital characteristics:
Making the link. J. Nurs. Adm. 2003, 33, 410–422. [CrossRef] [PubMed]
43. Upenieks, V.V. What’s the attraction to Magnet hospitals? Nurs. Manag. 2003, 34, 43–44. [CrossRef]
44. Armstrong, K.J.; Laschinger, H. Structural empowerment, Magnet hospital characteristics, and patient safety
culture: Making the link. J. Nurs. Care Qual. 2006, 21, 124–132. [CrossRef] [PubMed]
45. Laschinger, H.K.S.; Finegan, J.E.; Shamian, J.; Wilk, P. A longitudinal analysis of the impact of workplace
empowerment on work satisfaction. J. Organ. Behav. Int. J. Ind. Occup. Organ. Psychol. Behav. 2004, 25,
527–545. [CrossRef]
46. Cicolini, G.; Comparcini, D.; Simonetti, V. Workplace empowerment and nurses’ job satisfaction: A systematic
literature review. J. Nurs. Manag. 2014, 22, 855–871. [CrossRef]
47. Boamah, S.; Laschinger, H. Engaging new nurses: The role of psychological capital and workplace
empowerment. J. Res. Nurs. 2015, 20, 265–277. [CrossRef]
48. Donahue, M.O.; Piazza, I.M.; Griffin, M.Q.; Dykes, P.C.; Fitzpatrick, J.J. The relationship between nurses’
perceptions of empowerment and patient satisfaction. Appl. Nurs. Res. 2008, 21, 2–7. [CrossRef]
49. Laschinger, H.K.S. Effect of empowerment on professional practice environments, work satisfaction, and
patient care quality: Further testing the nursing worklife model. J. Nurs. Care Qual. 2008, 23, 322–330.
[CrossRef]
Int. J. Environ. Res. Public Health 2019, 16, 2381 14 of 15

50. Hayes, B.; Bonner, A.; Pryor, J. Factors contributing to nurse job satisfaction in the acute hospital setting:
A review of recent literature. J. Nurs. Manag. 2010, 18, 804–814. [CrossRef] [PubMed]
51. Boamah, S.A.; Read, E.A.; Spence Laschinger, H.K. Factors influencing new graduate nurse burnout
development, job satisfaction and patient care quality: A time-lagged study. J. Adv. Nurs. 2017, 73, 1182–1195.
[CrossRef] [PubMed]
52. Zhu, J.; Rodgers, S.; Melia, K.M. The impact of safety and quality of health care on Chinese nursing career
decision-making. J. Nurs. Manag. 2014, 22, 423–432. [CrossRef] [PubMed]
53. Sochalski, J. Quality of care, nurse staffing, and patient outcomes. Policy Politics Nurs. Pract. 2001, 2, 9–18.
[CrossRef]
54. Chang, C.-S. Moderating effects of nurses’ organizational support on the relationship between job satisfaction
and organizational commitment. West. J. Nurs. Res. 2015, 37, 724–745. [CrossRef] [PubMed]
55. Tsai, Y.; Wu, S.W. The relationships between organisational citizenship behaviour, job satisfaction and
turnover intention. J. Clin. Nurs. 2010, 19, 3564–3574. [CrossRef] [PubMed]
56. Havens, D.; Laschinger, H. Creating the Environment to Support Shared Governance Kanter’s Theory of
Power in Organizations. J. Shar. Gov. 1997, 3, 15–24.
57. Boamah, S. The Influence of Transformational Leadership on Nurse-Reported Patient Safety Outcomes (Electronic
Thesis and Dissertation Repository, UMI No. 4401); Western University: London, ON, Canada, 2017.
58. Manojlovich, M. Predictors of professional nursing practice behaviors in hospital settings. Nurs. Res. 2005,
54, 41–47. [CrossRef]
59. Manojlovich, M.; Laschinger, H. The nursing worklife model: Extending and refining a new theory. J. Nurs.
Manag. 2007, 15, 256–263. [CrossRef]
60. Podsakoff, P.M.; MacKenzie, S.B.; Lee, J.-Y.; Podsakoff, N.P. Common method biases in behavioral research:
A critical review of the literature and recommended remedies. J. Appl. Psychol. 2003, 88, 879–903. [CrossRef]
61. Carless, S.A.; Wearing, A.J.; Mann, L. A short measure of transformational leadership. J. Bus. Psychol. 2000,
14, 389–405. [CrossRef]
62. Cammann, C.; Fichman, M.; Jenkins, G.D.; Klesh, J. Assessing the Attitudes and Perceptions of Organizational
Members. In Assessing Organizational Change: A Guide to Methods, Measures, and Practices; Seashore, S.E.,
Lawler, E.E., III, Mirvis, P.H., Cammann, C., Eds.; Wiley: New York, NY, USA, 1983.
63. Aiken, L.H.; Clarke, S.P.; Sloane, D.M.; Consortium, I.H.O.R. Hospital staffing, organization, and quality of
care: Cross-national findings. Int. J. Qual. Health Care 2002, 14, 5–14. [CrossRef] [PubMed]
64. Qing, M.; Asif, M.; Hussain, A.; Jameel, A. Exploring the impact of ethical leadership on job satisfaction
and organizational commitment in public sector organizations: The mediating role of psychological
empowerment. Rev. Manag. Sci. 2019, 1–28. [CrossRef]
65. Jameel, A.; Asif, M.; Hussain, A. Good Governance and Public Trust: Assessing the Mediating Effect of
E-Government in Pakistan. Lex Localis J. Local Self Gov. 2019, 17, 299–320. [CrossRef]
66. Jöreskog, K.G.; Sörbom, D. Recent developments in structural equation modeling. J. Mark. Res. 1982, 404–416.
[CrossRef]
67. Bentler, P.M.; Bonett, D.G. Significance tests and goodness of fit in the analysis of covariance structures.
Psychol. Bull. 1980, 88, 588–606. [CrossRef]
68. Iacobucci, D. Structural equations modeling: Fit indices, sample size, and advanced topics. J. Consum.
Psychol. 2010, 20, 90–98. [CrossRef]
69. Shaffer, J.A.; DeGeest, D.; Li, A. Tackling the Problem of Construct Proliferation:A Guide to Assessing the
Discriminant Validity of Conceptually Related Constructs. Organ. Res. Methods 2016, 19, 80–110. [CrossRef]
70. Hair, J.F. Multivariate Data Analysis; Prentice Hall: Upper Saddle River, NJ, USA, 2010.
71. Hair, J.F.; Black, W.C.; Anderson, R.E.; Babin, B.J. Multivariate Data Analysis; Cengage Learning EMEA:
London, UK, 2018.
72. Fornell, C.; Larcker, D.F. Evaluating Structural Equation Models with Unobservable Variables and
Measurement Error. J. Mark. Res. 1981, 18, 39–50. [CrossRef]
73. Bagozzi, R.P.; Yi, Y. On the evaluation of structural equation models. J. Acad. Mark. Sci. 1988, 16, 74–94.
[CrossRef]
74. ILO (International Labour Organization). Improving Employment and Working Conditions in Health Services;
ILO: Geneva, Switzerland, 2017.
Int. J. Environ. Res. Public Health 2019, 16, 2381 15 of 15

75. Attari, M. The impact of transformational leadership on nurse psychological empowerment. Int. J. Hosp.
2013, 2, 71–76.
76. Morrison, R.S.; Jones, L.; Fuller, B. The relation between leadership style and empowerment on job satisfaction
of nurses. J. Nurs. Adm. 1997, 27, 27–34. [CrossRef] [PubMed]
77. Wong, C.A.M.; Giallonardo, L. Authentic leadership and nurse-assessed adverse patient outcomes. J. Nurs.
Manag. 2013, 21, 740–752. [CrossRef] [PubMed]
78. Bass, B.M. Two decades of research and development in transformational leadership. Eur. J. Work Organ.
Psychol. 1999, 8, 9–32. [CrossRef]
79. Arnold, K.A.; Connelly, C.E.; Walsh, M.M.; Martin Ginis, K.A. Leadership styles, emotion regulation, and
burnout. J. Occup. Health Psychol. 2015, 20, 481–490. [CrossRef] [PubMed]
80. Polit, D.F.; Beck, C.T. Nursing Research: Generating and Assessing Evidence for Nursing Practice; Lippincott
Williams & Wilkins: Philadelphia, PA, USA, 2008.
81. Cavanagh, S.J.; Coffin, D.A. Staff turnover among hospital nurses. J. Adv. Nurs. 1992, 17, 1369–1376.
[CrossRef] [PubMed]
82. Peng, J.; Li, D.; Zhang, Z.; Tian, Y.; Miao, D.; Xiao, W.; Zhang, J. How can core self-evaluations influence job
burnout? The key roles of organizational commitment and job satisfaction. J. Health Psychol. 2016, 21, 50–59.
[CrossRef]
83. Podsakoff, P.M.; Organ, D.W. Self-reports in organizational research: Problems and prospects. J. Manag.
1986, 12, 531–544. [CrossRef]

© 2019 by the authors. 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 (http://creativecommons.org/licenses/by/4.0/).