Received: 18 June 2021 | Revised: 5 October 2021 | Accepted: 18 November 2021

DOI: 10.1111/jnu.12756

Transformational leadership as a mediator between

work–­family conflict, nurse-­reported patient safety outcomes,
and job engagement

Leodoro J. Labrague DM, PhD, CHSE, CNE1,2 | Arwa Atef Obeidat RN, MSN1

1
Sultan Qaboos University, Muscat,
Sultanate of Oman Abstract
Purpose: Work–­family conflict (WFC) is an important issue in nursing administra-
2
St. Paul University Philippines,
Tuguegarao, Philippines
tion and management that is associated with reduced work effectiveness and patient
Correspondence safety issues. To date, very few studies have attempted to explain the mechanisms
Leodoro J. Labrague, Sultan Qaboos
University, Muscat, Sultanate of Oman.
underlying these relationships. The aim of this study was to determine the influence
Email: Leo7_ci@yahoo.com of work–­family conflict (WFC) on patient safety outcomes and job engagement via the
intermediary role of transformational leadership (TL).
Design: Cross-­sectional study.
Methods: Seven hundred fifty-­
four nurses from 10 acute care hospitals in the
Philippines were included in this cross-­sectional study.
Findings: A higher perception of WFC was associated with increased adverse events,
reduced quality of care and decreased job engagement. WFC was indirectly associ-
ated with quality of care, adverse events and job engagement through the intermedi-
ary of TL.
Conclusions: The results of this study underscore the important role of nurse manag-
ers’ TL in sustaining work–­family balance and, in turn, improving patient safety out-
comes and enhancing job engagement among nurses.
Clinical relevance: Institutional measures to foster patient safety outcomes and sus-
tain the nursing workforce should involve enhancing nurse managers’ leadership
behaviors through theory-­driven interventions, periodic leadership assessment, and
implementation of leadership development activities. WFC may be addressed by cre-
ating empowering work conditions, providing adequate coaching and mentorship to
nurses, and implementing work–­family friendly policies in the workplace.

KEYWORDS
adverse patient events, nursing, quality of care, job engagement, transformational leadership

Patient safety, a vital indicator of a quality healthcare delivery sys-
tem, remains an important issue that plagues many healthcare sys-
tems around the world. Despite efforts to curtail and prevent patient
safety errors, a wide range of studies conducted across countries
suggested that many healthcare systems are vulnerable to these
errors and adverse patient events (Kim et al., 2020; Lee & Quinn,
2020). The Institute of Global Health Innovation (2019) reported
that these preventable errors have caused approximately 420 mil-
lion hospitalizations and 5.7 to 8.4 million lives in previous years, as
well as massive economic and health concerns in many countries,
particularly in underdeveloped and developing regions. This issue is
exacerbated by the aging nurse population, the increasing rate of

J Nurs Sch. 2022;54:493–500. wileyonlinelibrary.com/journal/jnu

© 2021 Sigma Theta Tau International. | 493
494 | OUTCOMES OF TRANSFORMATIONAL LEADERSHIP
actual nurse turnover, and the increasing percentage of nurses who
intend to leave their jobs (World Health Organization, 2020).
In recent years, numerous studies have been undertaken in an
effort to identify factors contributing to patient safety issues and
ways to address them, with most research finding that nurse-­related
factors are among the major determinants of patient safety (Lee &
Quinn, 2020). Effective leadership and different dimensions of the
nurse work environment, including whether staffing and hospital
resources are adequate, staff involvement in hospital affairs, the
presence of effective management and leadership, the provision
of adequate support and solid relations between nurses and physi-
cians, were found to strongly influence patient safety outcomes and
quality of care (Mihdawi et al., 2020; Motamedzadeh et al., 2017).
Work–­family conflict (WFC) received less attention in relation to
patient safety outcomes, although the literature identified increased
patient workload and job stress, which are important predictors of
WFC, to be strongly linked to poorer nursing care provision and re-
duced nursing care quality (Bautista et al., 2020; Chen et al., 2021).
Given the stressful nature of the nursing job and the complex re-
sponsibilities and roles of a nurse, balancing work and family respon-
sibilities can be a major challenge. An inability to harmonize these
two roles could potentially lead to WFC, a circumstance in which the
demand in an individual's work role clashes with their family roles
(Kossek & Lee, 2017), resulting in poor work performance, height-
ened levels of emotional exhaustion and psychological distress, in-
creased absenteeism and increased nurse turnover (Haji Matarsat
et al., 2021; Labrague et al., 2020; Munir et al., 2012). Earlier reports
have identified a higher frequency of patient safety concerns, in-
cluding adverse patient events, near misses, and nursing care left
undone, in nurses who experience psychological and mental health-­
related problems such as emotional exhaustion, job stress and anxi-
ety (Bautista et al., 2020).
Given the wide array of negative consequences of WFC, it is im-
perative that organizational measures be established to prevent the
negative work–­family spillover that could adversely affect not only
patient safety but also nurse and organizational outcomes. Research
has identified that adequate organizational support and the provi-
sion of a work environment that supports work–­family balance (e.g.
flexible work schedule, reasonable pay, adequate professional au-
tonomy, sufficient manpower, and hospital resources) can reduce
the occurrence of WFC (Chen et al., 2021; Suresh & Kodikal, 2017).
Although a myriad of evidence has shown that effective leadership
creates an empowering work environment that supports subordi-
nates’ needs and addresses their concerns, including those related to
family affairs (Braun & Nieberle, 2017), nurse managers’ leadership
practices are rarely studied in relation to nurses’ perceptions of WFC
(Munir et al., 2012).
Transformational leadership (TL) is a widely known style of lead-
ership based on relationships that are associated with sustained
work effectiveness and overall organizational productivity (Bass &
Avolio, 1994). Transformational leaders create favorable work en-
vironments that empower nurses, both structurally and psycholog-
ically, to attain higher-­order goals, resulting in more sustained job
performance, work motivation, and job engagement and leading to
optimal patient care (Wang et al., 2021; Xie et al., 2020). Moreover,
a leader demonstrating TL engages substantially in individualized
consideration through mentoring or coaching to attend to the needs
of their individual subordinates, helping them fulfill their job role
while considering their family roles (Avolio et al., 2004). Additionally,
transformational leaders assist their followers in developing strate-
gies and coming up with new ideas to effectively handle job respon-
sibilities, as well as offer solutions to better handle issues that may
arise due to the demands of the family and work roles (Sanchez et al.,
2020). Previous studies found greater confidence in handling and
reconciling work–­family issues among followers who worked under
a leader who demonstrated TL, resulting in increased work content-
ment and job productivity (Arthi & Sumathi, 2020; Avolio & Bass,
2002; Gillet et al., 2016). Given this evidence, it is highly possible
that TL of nurses could buffer the negative impact of WFC on patient
safety outcomes and job engagement. Hence, the present study was
conducted to fill in this gap in the nursing literature by examining
how WFC affects patient safety outcomes and job engagement, via
the intermediary role of TL. We hypothesized that (a) WFC is directly
associated with nurse-­assessed patient safety outcomes and job en-
gagement, (b) nurse managers’ TL is directly associated with nurse-­
assessed patient safety outcomes and job engagement and (c) WFC
is indirectly associated with nurse-­assessed patient safety outcomes
and job engagement through TL.
M E TH O D S
Design, samples and settings
This study employed a cross-­sectional design to gather data from
clinical nurses working in 10 acute care hospitals in the Western
Visayas Region of the Philippines. These hospitals were chosen ran-
domly from a list of all hospitals in the region. A two-­stage sampling
method was used in the recruitment of the participants: stratified
sampling in determining the number of nurses per hospital (Stage
1) and convenience sampling in the selection of the respondents in
each hospital (Stage 2). Registered nurses who held a full-­or part-­
time job and had at least six months of work experience in their
present unit were qualified to participate in the study. To identify
the necessary number of participants, we used the online sample
calculator by Soper (2021). To achieve 80% power with a small ef-
fect size of 0.02 and an alpha of 0.05, a sample size of 543 nurses
was determined to be sufficient. To account for possible attrition,
the desired sample size was increased to 800. A total of 754 nurses
completed the questionnaire.
Instrumentation
Nurse managers’ TL was appraised using the Global Transformational
Leadership (GTL) Scale (Carless et al., 2000). This scale, which
OUTCOMES OF TRANSFORMATIONAL LEADERSHIP
comprises 7 items, has been widely validated in nursing and non-­
nursing populations to measure TL (Lavoie-­Tremblay et al., 2016).
Each point on the scale was scored using a 5-­point Likert-­t ype scale
from 1 (“never”) to 5 (“almost always”). Previous studies demon-
strated that the GTL Scale has an acceptable reliability index, with an
internal consistency value of 0.92 (Labrague et al., 2020) and excel-
lent validity (predictive and convergent; Carless et al., 2000; Lavoie-­
Tremblay et al., 2016).
Using the Work–­Family Conflict (WFC) Scale, nurses reported
their perspectives of any imbalance between their own work and
family roles (Netemeyer et al., 1996). Each of the five items on the
scale was scored using a Likert-­t ype scale from 1 (“strongly disagree”)
to 5 (“strongly agree”). The reliability and validity of the scale were
found to be excellent in previous research (Netemeyer et al., 1996).
Nurses’ job engagement was assessed using the 9-­item Utrecht
Work Engagement Scale (UWES-­9; Schaufeli et al., 2006). This scale
consists of 9 items classified into three dimensions: “vigor”, “ded-
ication,” and “absorption”. Nurses responded to each item using a
seven-­point Likert-­t ype scale from 1 (“never”) to 7 (“always”). Earlier
research established the reliability of the scale, reporting an internal
consistency value of 0.90 (Tabataba'i-­Nasab et al., 2017). Research
involving nurses established the predictive and criterion validity of
the scale (Tabataba'i-­Nasab et al., 2017).
Two indicators of patient safety outcomes were measured in this
study: the nurse-­appraised quality of nursing care and adverse pa-
tient events. A single-­item measure with a 5-­point Likert-­t ype scale
(0 for “poor” to 5 for “excellent”) was used to examine the nurses’ ap-
praisal of the quality of nursing care in their assigned unit. Adverse
events involving patients and their families were reported using a
self-­rated scale, the APE scale. Nurses reported the frequency of
each event (e.g. complaints and abuse from patients and/or families,
falls, nosocomial infections and drug administration errors) in the
past year using a Likert-­t ype scale. The reliability and validity of both
scales were found to be acceptable in previous research (Labrague,
2020).
The internal consistency values of the scale in the present study
were: 0.91 (GTLS), 0.87 (WFCS) and 0.84 (UWES-­9).
Ethical considerations
Before data collection, the primary researcher sought the permis-
sion of the nursing directors of the hospitals in the region. After
permission was granted, four trained research assistants (RAs) iden-
tified prospective participants based on the inclusion criteria. Once
identified, the participants were provided a short orientation about
the research and how to complete the survey questionnaires. No
personal information was collected from the participants, although
each questionnaire was assigned a unique code for accounting pur-
poses. In addition, all participants were informed of their full rights
as research participants, including the right to withdraw from the
study. Using a pen and paper, the participants completed the ques-
tionnaires during their break time. Once completed, the surveys
| 495
were handed back to the RAs in enclosed envelopes. Data collection
commenced in October 2019 and ended in December 2020. The re-
view and ethical committee of the affiliated university approved the
research protocol of the study.
Data analysis
The software program SPSS version 23 (IBM Corp.) was used to ana-
lyse the data. The correlation between nurse variables and selected
study variables was analyzed using bivariate statistics, including
analysis of variance, independent t-­test and Pearson's correlation
coefficient (r). The three-­step guide by Baron and Kenny (1986) was
followed to test the intermediary effect of TL. First, the direct ef-
fect of WFC on outcome variables (patient safety outcomes and
job engagement) was examined using multiple regression analysis.
Next, the mediator variable was regressed to the outcome variables
using a similar statistical test. Finally, the indirect effect of WFC on
the outcome variables, via the mediating role of TL, was examined
using multiple regression analysis. Key study variables are reported
as means, frequencies, and percentages.
R E S U LT S
Seven hundred fifty-­four nurses completed the questionnaire. More
than half of the participants were female (60.6%), not married (54%)
and held baccalaureate degrees in nursing (75%) and a full-­time role
(85.6%). Nurses’ average age and work experience in the nursing
profession were 30.31 and 7.11 years, respectively. The detailed
characteristics of nurses are shown in Table 1.
The mean scale scores in the WFC and TL scales were 3.179 (out
of 5) and 4.276 (out of 5), respectively. The mean scale scores in the
QoC and APE scales were 3.307 (out of 4) and 1.783 (out of 4), re-
spectively. The mean scale score in the job engagement measure was
3.364 (out of 5). TL was correlated with all variables in the hypoth-
esized direction. TL had a significant and positive correlations with
job engagement (r = 0.331, p < 0.05) and quality of care (r = 0.314,
p < 0.05). Further, TL had significant but negative correlations with
WFC (r = −0.990, p < 0.05) and adverse events (r = 0.288, p < 0.05).
Meanwhile, WFC had significant but negative correlations with job
engagement (r = −0.161, p < 0.05) and quality of care (r = −0.225,
p < 0.05) and a positive correlation with adverse events (r = 0.154,
p < 0.05; Table 2).
Multi-­
phase regression analyses were conducted to examine
the mediating effect of WFC (Table 3). First, the independent vari-
able (WFC) was regressed to the outcome variables (patient safety
outcomes and job engagement). Regression analyses showed that
a higher score on the WFC scale was associated with increased
adverse events (β = 0.154, p < 0.001), reduced quality of care
(β = −0.225, p < 0.001) and decreased job engagement in nurses
(β = −0.161, p < 0.001). Next, the independent variable (WFC) was
regressed to the mediator variable (TL). Higher WFC scores were
496 | OUTCOMES OF TRANSFORMATIONAL LEADERSHIP

associated with decreased scores in the TL measure (β = −0.099, (WFC). TL partially mediated the relationships between (a) WFC and
p < 0.001). Finally, the mediator variable was regressed to the de- quality of care (β = −0.196, p < 0.001), (b) WFC and adverse events
pendent variables while controlling for the independent variable (β = 0.127, p < 0.001) and (c) WFC and job engagement (β = −0.130,
p < 0.001). Sobel tests confirmed the significance of the mediating
TA B L E 1 Staff, unit, and hospital characteristics (n = 754) effects of WFC on the relationship between TL and quality of care
(z = 2.846, p = 0.004), adverse events (z = −2.687, p = 0.007) and job
Characteristics Categories Mean SD
engagement (z = 2.740, p = 0.006).
Age 30.31 6.05
Year in Nursing Profession 7.11 5.50
Year in the Present Unit 3.70 3.26 DISCUSSION
Year in Present 30.31 6.05
Organization Overall, the study findings supported the hypothesized model: that a
n % higher TL rating of nurse managers would be directly associated with
Gender Male 297 39.4 patient safety outcomes and job engagement. Moreover, WFC was
Female 457 60.6 directly and indirectly associated with patient safety outcomes and
Marital status Married 347 46.0 job engagement via the mediating effects of TL.

Unmarried 407 54.0 Consistent with previous international reports in which many
nurses and nurse managers reported having a preference for
Education BSN 566 75.0
TL over other leadership styles (Labrague et al., 2020; Lavoie-­
MA/MS 189 25.0
Tremblay et al., 2016; Xie et al., 2020), nurses in the present study
Job status Fulltime 645 85.6
perceived their nurse managers to be transformational leaders.
Part-­time 109 14.4
Meanwhile, the mean score on the WFC scale indicates that WFC
Assigned Area/Unit Surgery 119 15.8
was experienced by nurses at a modest level. This result, while
Medicine 212 28.1 low compared to scores in Asian, Middle East, and Western na-
Gynecology 102 13.5 tions (Galetta et al., 2019; Hassanzadeh et al., 2019), is in accor-
Emergency 127 16.8 dance with an earlier study in the local context (Labrague et al.,
Intensive/Critical 75 10.0 2020).
Pediatric 84 11.1 In accordance with earlier reports, this study found that a higher
Operating 14 1.8 perception of WFC was associated with more adverse events,
Theater poorer nursing care quality, and decreased work engagement among
others 23 3.0 nurses (Hassanzadeh et al., 2019; Labrague et al., 2020). Failure to
Type of hospital Private 375 49.7 balance work and family responsibilities may result in role stress and
Public 379 50.3 emotional exhaustion, having a negative effect on nurses’ capacity

Hospital level Primary 90 11.9

to implement safe and effective nursing care. Numerous studies
have identified that the physiological (e.g. cardiovascular issues,
Secondary 236 31.3
sleep disturbance; Berkman et al., 2015) and psychological (e.g.
Tertiary 428 56.8
burnout, stress, anxiety; Zurlo et al., 2020) spillover effects of WFC
Hospital facility size <100 beds 163 21.6
have profound effects on nurses’ ability to provide safe nursing care,
101–­250 beds 325 43.1
resulting in near misses, adverse events and patient complications.
>250 beds 266 35.3
Other studies have associated WFC with decreased job satisfaction,
Hospital location Urban 595 78.9 frequent absenteeism, and lower job commitment (Tabataba'i-­Nasab
Rural 159 21.1 et al., 2017; Xie et al., 2020).

TA B L E 2 Correlations between key study variables

Variables Mean SD 1 2 3 4 5

1. Work family conflict 3.179 0.653 1

2. Transformational leadership 4.276 0.614 −0.990** 1
3. Job engagement 3.364 0.609 −0.161** 0.331** 1
4. Quality of care 3.307 0.548 −0.225** 0.314** 0.248** 1
5. Adverse events 1.783 1.040 0.154** −0.288** −0.164** −0.193** 1

Note: **p<0.001
OUTCOMES OF TRANSFORMATIONAL LEADERSHIP | 497

TA B L E 3 Effect estimates

Structural Paths B SE β t p LB UB

Direct Effects
Work family conflict →adverse events 0.246 0.049 0.154 5.062 0.001 0.150 0.341
Work family conflict →quality of care −0.189 0.025 −0.225 −7.472 0.001 −0.238 −0.139
Work family conflict →job engagement −0.151 0.028 −0.161 −5.304 0.001 −0.206 −0.095
Work family conflict Transformational −0.093 0.029 −0.099 −3.217 0.001 −.150 −0.036
leadership →
Transformational leadership →adverse −0.488 0.050 −0.288 −9.759 0.001 −0.586 −0.390
events
Transformational leadership →quality of 0.280 0.026 0.314 10.714 0.001 0.229 0.331
care
Transformational leadership →job 0.328 0.029 0.331 11.376 0.001 0.272 0.385
engagement
Indirect Effects
Work family conflict →Transformational 0.202 0.047 0.127 4.316 0.001 0.110 0.294
leadership →Adverse events
Work family conflict →Transformational −0.164 0.024 −0.196 −6.784 0.001 −0.212 −0.117
leadership →quality of care
Transformational leadership →Work family −0.121 0.027 −0.130 −4.486 0.001 −0.174 −0.068
conflict →job engagement

Nurse managers’ TL was directly associated with nurse-­appraised
adverse events and quality of nursing care. In other words, when
nurses perceive their nurse managers to be transformational lead-
ers, they tend to report a higher quality of nursing care and fewer
adverse events, as well as a higher level of job engagement. TL is
an effective leadership style: transformational leaders intellectually
stimulate their subordinates, prompting them to keep themselves
updated with the current trends in professional practice through
formal and informal education, to propose new solutions based on
science and to use research and empirical evidence in the care of
patients (Avolio et al., 2004). Further, a leader demonstrating TL
empowers nurses to speak out and communicate or report errors,
recognize patient care issues and implement immediate care man-
agement, resulting in reduced patient safety complications and im-
proved nursing care provision (Boamah et al., 2018; Fischer, 2016).
This result corroborates the findings of earlier studies that identified
transformational leaders as individuals who create a positive work
climate in which nurses feel capable and empowered to provide
optimal and standard nursing care (Labrague et al., 2020; Lavoie-­
Tremblay et al., 2016).
The direct effect of nurse managers’ TL on staff nurses’ job
engagement identified in this study is in accordance with earlier
research, which identified TL as an important precursor of vari-
ous job outcomes in nurses, including work engagement (Labrague
et al., 2020; Tabataba'i-­Nasab et al., 2017). This finding was ex-
pected, as nurse managers demonstrating TL are able to help
their subordinates maximize their full potential through construc-
tive feedback, adequate mentoring and coaching, and sufficient
structural support (Bass & Avolio, 1994), resulting in a highly
engaged workforce. Further, through ‘intellectual stimulation’, a
transformational leader values subordinates’ ideas and opinions
on issues relevant to the unit or organization, thereby enhanc-
ing their sense of belonging, making them more engaged at work
(Avolio et al., 2004). Transformational leaders create a favorable
work environment in which information, resources, opportunities
and support are in place to foster individual employees’ work per-
formance, work contentment and job engagement, and to reduce
their intent to quit their job (Boamah et al., 2018; Lavoie-­Tremblay
et al., 2016). The direct effect of TL on individuals’ work engage-
ment was likewise observed in prior studies from non-­nursing sec-
tors, including studies from the academe, business, banking and
the service and tourism industries (Ali Ababneh et al., 2021; Wang
et al., 2021).
One of the key findings of the study was the intermediary effect
of TL in the association between WFC and job engagement. Nurses
who perceived their nurse managers to be transformational leaders
tended to experience less work–­family conflict, which had the ef-
fect of increasing their job engagement. We conducted an extensive
literature review, and to our knowledge, this study is the first to re-
port such an interesting and valuable finding, thus providing new
knowledge in this vital area in nursing science. This result can best
be explained by the ability of a transformational leader to engage in
individualized consideration in which followers’ needs are individu-
ally attended; such a leader provides adequate coaching, mentoring
and guidance (Avolio et al., 1999) so that their followers can effec-
tively balance the demands of their family and work roles (Munir
et al., 2012). Previous reports identified nurses’ capacity to balance
their work and family responsibilities as a strong determinant of job
contentment and job engagement (Labrague et al., 2020; Tabataba'i-­
Nasab et al., 2017).
498 | OUTCOMES OF TRANSFORMATIONAL LEADERSHIP
The intermediary role of WFC on the association between TL
and nurse-­
assessed patient safety outcomes, although not sur-
prising, is a novel finding, as to our knowledge, this study was the
first to determine such interrelationships. Although there is a wide
range of evidence directly linking TL with numerous patient safety
outcomes, both actual and nurse-­reported, including patient falls,
healthcare-­
related infection, drugs administration errors, bed-
sores, and urinary tract infections (Boamah et al., 2018; Fischer,
2016), the mechanisms underlying these relationships remain un-
known. This result revealed the important role of TL in explaining
the interaction between WFC and patient safety outcomes. This
could be because relational leadership styles, including TL, en-
able an empowering work environment in which staff nurses are
provided greater discretion over their job and more professional
authority over their nursing practice, allowing them to achieve
work–­f amily balance, ultimately improving patient outcomes (Ree,
2020; Singh, 2020). Further, a leader demonstrating TL encour-
ages decision-­making and problem-­solving skills, which are known
to have a positive influence on the individual's ability to reconcile
family and job demands, which subsequently leads to better nurs-
ing care provision and fewer patient safety concerns (Boamah et al.,
2018; Weeks et al., 2014).
Limitations of the study
Nurses included in this study were confined to only one region in
the country; hence, the generalization of the findings could be a
challenge. The use of a self-­reported scale to assess adverse events
and quality of care through nurses’ own perceptions could cre-
ate a bias. Therefore, future research utilizing more rigorous data
gathering procedures, such as chart review (prospective or retro-
spective) or observation, may yield more meaningful findings. The
mediating role of TL between WFC and the outcome variables sug-
gests that other potential factors (individual or contextual) may not
have been accounted for and should therefore be considered in
future studies.
C LI N I C A L I M PLI C ATI O N S
The results of the present study underscore the need to sustain a
balance between the demands of the job and the family in nurses,
as well as to foster TL among nurse managers, through relevant or-
ganizational policies, empirically tested interventions, and effective
leadership and management. Periodic assessment of leadership be-
haviors in nurse managers is important to gain knowledge related
to their leadership needs and areas for improvement. This can be
achieved using an effective performance evaluation tool, such as
360-­degree (Qureshi, 2020). TL in nurses can be fostered by em-
ploying leadership development training (e.g. leadership simulation,
leadership education, encouraging nurse managers to take relevant
certifications and further education; Singh, 2020).
Nurse managers can best address WFC by creating empowering
work conditions in which nurses are provided reasonable workloads,
flexible work schedules and breaks, and adequate labor and hospi-
tal resources to effectively fulfill their professional roles (Arthi &
Sumathi, 2020). Further, nurse managers should provide support to
nurses through coaching and/or mentoring by senior nurses to em-
power them to handle their work and family roles effectively (Zurlo
et al., 2020). Implementing organizational policies that promote
family–­work balance may enable nurses to harmonize their work and
family responsibilities (Munir et al., 2012).
CO N C LU S I O N S
Filipino nurses perceived their nurse managers to be highly transfor-
mational leaders and reported moderate levels of WFC. The results
of this study suggest that WFC may threaten nurses’ work outcomes
and the overall provision of safe and quality nursing care. Moreover,
the study findings yielded additional contributions to nursing sci-
ence regarding the importance of reinforcing TL in nurse managers
as an organizational strategy to reduce WFC, address patient care
issues and ultimately improve patient safety outcomes and maintain
a highly engaged nursing workforce.
AC K N OW L E D G M E N T S
The authors would like to acknowledge and thanks all nurses who
participated in the study.
AU T H O R S H I P S TAT E M E N T
All authors listed meet the authorship criteria according to the
latest guidelines of the International Committee of Medical
Journal Editors, and ii) that all authors are in agreement with the
manuscript.
CLINICAL RESOURCES
• Work Life Balance. https://www.mhana​tional.org/work-­life-­balance
• A closer look at the effects of transformational leadership.
https://www.veryw​ellmi​nd.com/what-­is-­trans​forma​tiona​l-­leade​
rship​-­2795313
C O N FL I C T O F I N T E R E S T
All authors declare no conflict of interest.
E T H I C A L C O N S I D E R AT I O N S
Prior to data collection, the research protocol was submitted to the
Institutional Research Ethics Committee of Samar State University
(IRERC EA-­0 03-­E), for ethical clearance.
RESE ARCH FUND
This study is non-­funded.
ORCID
Leodoro J. Labrague https://orcid.org/0000-0003-0315-4438
OUTCOMES OF TRANSFORMATIONAL LEADERSHIP
REFERENCES
Ali Ababneh, O. M., Awwad, A. S., & Abu-­Haija, A. (2021). The associ-
ation between green human resources practices and employee
engagement with environmental initiatives in hotels: The mod-
eration effect of perceived transformational leadership. Journal
of Human Resources in Hospitality & Tourism, 1–­27. https://doi.
org/10.1080/15332​8 45.2021.1923918
Arthi, R., & Sumathi, G. N. (2020). Work-­family conflict and professional
commitment: Proactive effect of transformational leadership.
Problems and Perspectives in Management, 18(1), 97–­106.
Avolio, B. J., & Bass, B. M. (2002). Developing potential across a full range
of leadership cases on transactional and transformational leadership.
Lawrence Erlbaum Associates.
Avolio, B. J., Bass, B. M., & Jung, D. I. (1999). Re-­examining the com-
ponents of transformational and transactional leadership using the
Multifactor Leadership Questionnaire. Journal of Occupational and
Organizational Psychology, 72, 441–­462.
Avolio, B. J., Zhu, W., Koh, W., & Bhatia, P. (2004). Transformational
leadership and organizational commitment: Mediating role of psy-
chological empowerment and moderating role of structural dis-
tance. Journal of Organizational Behavior: The International Journal of
Industrial, Occupational and Organizational Psychology and Behavior,
25(8), 951–­968. https://doi.org/10.1002/job.283
Baron, R. M., & Kenny, D. A. (1986). The moderator-­mediator variable
distinction in social psychological research: Conceptual, strate-
gic, and statistical considerations. Journal of Personality and Social
Psychology, 51, 1173–­1182.
Bass, B. M., & Avolio, B. J. (1994). Transformational leadership and orga-
nizational culture. The International Journal of Public Administration,
17(3–­4), 541–­554. https://doi.org/10.1080/01900​69940​8524907
Bautista, J. R., Lauria, P. A. S., Contreras, M. C. S., Maranion, M. M. G.,
Villanueva, H. H., Sumaguingsing, R. C., & Abeleda, R. D. (2020).
Specific stressors relate to nurses’ job satisfaction, perceived qual-
ity of care, and turnover intention. International Journal of Nursing
Practice, 26(1), e12774. https://doi.org/10.1111/ijn.12774
Berkman, L. F., Liu, S. Y., Hammer, L., Moen, P., Klein, L. C., Kelly, E., &
Buxton, O. M. (2015). Work–­family conflict, cardiometabolic risk,
and sleep duration in nursing employees. Journal of Occupational
Health Psychology, 20(4), 420. https://doi.org/10.1037/a0039143
Boamah, S. A., Laschinger, H. K. S., Wong, C., & Clarke, S. (2018). Effect
of transformational leadership on job satisfaction and patient
safety outcomes. Nursing Outlook, 66(2), 180–­189. https://doi.
org/10.1016/j.outlo​ok.2017.10.004
Braun, S., & Nieberle, K. W. (2017). Authentic leadership extends beyond
work: A multilevel model of work-­family conflict and enrichment.
The Leadership Quarterly, 28(6), 780–­797. https://doi.org/10.1016/j.
leaqua.2017.04.003
Carless, S. A., Wearing, A. J., & Mann, L. (2000). A short measure of
transformational leadership. Journal of Business and Psychology,
14(3), 389–­4 05.
Chen, I. C., Lee Peng, N., Hui Fuang, N., & Lok Sin, K. (2021). Impacts
of job-­related stress and patient safety culture on patient safety
outcomes among nurses in Taiwan. International Journal of
Healthcare Management, 14(1), 1–­9. https://doi.org/10.1080/20479​
700.2019.1603419
Chen, X., Li, Q., Xu, F., & Han, B. (2021). The mediating role of resil-
ience between work–­ family conflict and career development
among Chinese nurses: A cross-­sectional study. Journal of Nursing
Management. Ahead of print.
Fischer, S. A. (2016). Transformational leadership in nursing: A concept
analysis. Journal of Advanced Nursing, 72(11), 2644–­2653. https://
doi.org/10.1111/jan.13049
Galletta, M., Portoghese, I., Melis, P., Gonzalez, C. I. A., Finco, G., D’Aloja,
E., & Campagna, M. (2019). The role of collective affective com-
mitment in the relationship between work–­ family conflict and
| 499
emotional exhaustion among nurses: A multilevel modeling ap-
proach. BMC Nursing, 18(1), 1–­9. https://doi.org/10.1186/s1291​
2-­019-­0329-­z
Gillet, N., Fouquereau, E., Huyghebaert, T., & Vandenberghe, C. (2016).
Transformational leadership, work-­family conflict and enrichment,
and commitment. Le Travail Humain, 79(4), 339–­362. https://doi.
org/10.3917/th.794.0339
Haji Matarsat, H. M., Rahman, H. A., & Abdul-­Mumin, K. (2021). Work-­
family conflict, health status and job satisfaction among nurses.
British Journal of Nursing, 30(1), 54–­58. https://doi.org/10.12968/​
bjon.2021.30.1.54
Hassanzadeh, M., Abazari, F., & Farokhzadian, J. (2019). The work–­family
conflict and quality of care given by nurses: a cross-­sectional ques-
tionnaire survey. Journal of Public Health, 1–­6. Ahead of print.
Institute of Global Health Innovation. (2019). The global state of patient
safety. Retrieved June 13, 2021, from https://www.imper​ial.ac.uk/
media/ ​ i mper ​ i al- ­c olle ​ g e/insti ​ t ute- ­o f-­g loba ​ l -­h ealt ​ h -­i nnov ​ a tion/​
Globa​lStat​eofPS_DIGIT​AL_16Sep​19[2].pdf
Kim, S., Shin, H. G., Jo, A. J., Min, A., Ock, M., Hwang, J. I., & Lee, S.
I. (2020). Variation between hospitals and reviewers in detection
of adverse events identified through medical record review in Korea.
International Journal for Quality in Health Care, 32(8), 495–­501.
https://doi.org/10.1093/intqh​c/mzaa079
Kossek, E. E., & Lee, K. H. (2017). Work-­family conflict and work-­life con-
flict. In Oxford research encyclopedia of business and management.
Labrague, L. J., Ballad, C. A., & Fronda, D. C. (2020). Predictors and out-
comes of work–­family conflict among nurses. International Nursing
Review. Ahead of print.
Labrague, L. J., Nwafor, C. E., & Tsaras, K. (2020). Influence of toxic and
transformational leadership practices on nurses’ job satisfaction,
job stress, absenteeism and turnover intention: A cross-­sectional
study. Journal of Nursing Management, 28(5), 1104–­1113. https://
doi.org/10.1111/jonm.13053
Lavoie-­Tremblay, M., Fernet, C., Lavigne, G. L., & Austin, S. (2016).
Transformational and abusive leadership practices: Impacts on nov-
ice nurses, quality of care and intention to leave. Journal of Advanced
Nursing, 72(3), 582–­592. https://doi.org/10.1111/jan.12860
Lee, S. E., & Quinn, B. L. (2020). Safety culture and patient safety outcomes
in East Asia: A literature review. Western Journal of Nursing Research,
42(3), 220–­230. https://doi.org/10.1177/01939​45919​848755
Mihdawi, M., Al-­Amer, R., Darwish, R., Randall, S., & Afaneh, T. (2020). The
influence of nursing work environment on patient safety. Workplace
Health & Safety, 68(8), 384–­390. https://doi.org/10.1177/21650​
79920​901533
Motamedzadeh, M., Mahmoudi, H., Nehrir, B., & Ebadi, A. (2017).
Patient safety in nursing: A systematic review. International
Journal of Medical Reviews, 4(2), 52–­57. https://doi.org/10.29252/​
ijmr-­0 40205
Munir, F., Nielsen, K., Garde, A. H., Albertsen, K., & Carneiro, I. G. (2012).
Mediating the effects of work–­life conflict between transforma-
tional leadership and health-­c are workers’ job satisfaction and psy-
chological wellbeing. Journal of Nursing Management, 20(4), 512–­
521. https://doi.org/10.1111/j.1365-­2834.2011.01308.x
Netemeyer, R. G., Boles, J. S., & McMurrian, R. (1996). Development and
validation of work–­family conflict and family–­work conflict scales.
Journal of Applied Psychology, 81(4), 400–­410. https://doi.org/10.10
37/0021-­9010.81.4.400
Qureishi, H. (2020). 360 degree performance effects on employee at-
titude, professional effectiveness and general work performance.
Research Review International Journal of Multidisciplinary, 5(4),
56–­69.
Ree, E. (2020). What is the role of transformational leadership, work en-
vironment and patient safety culture for person-­centred care? A
cross-­sectional study in Norwegian nursing homes and home care
services. Nursing Open, 7(6), 1988–­1996. https://doi.org/10.1002/
nop2.592
500 | OUTCOMES OF TRANSFORMATIONAL LEADERSHIP
Sánchez, I. D., Andrade, J. M., & Losada-­Otálora, M. (2020). Beyond or-
ganisational boundaries: the complex relationship between trans-
formational leadership, organisational justice, and work-­ family
conflict. International Journal of Human Resources Development
and Management, 20(3–­4), 322–­3 48. https://doi.org/10.1504/
IJHRDM.2020.107990
Schaufeli, W. B., Bakker, A. B., & Salanova, M. (2006). The measurement
of work engagement with a short questionnaire: A cross-­national
study. Educational and Psychological Measurement, 66(4), 701–­716.
https://doi.org/10.1177/00131​6 4405​282471
Singh, A. (2020). Implementation and evaluation of a transformational
leadership education session for nurse leaders and nurse educa-
tors. Journal of Doctoral Nursing Practice. Ahead of Print.
Suresh, S., & Kodikal, R. (2017). SEM approach to explore Work Life
Balance: A study among nurses of Multispecialty Hospitals. SJOM
Journal of Management, 1(1), 1–­17.
Soper, D. (2021). A-­priori sample size calculator for multiple regression.
http://www.danie​lsoper.com/statc​alc/calcu​lator.aspx?id=1
Tabataba'i-­N asab, S. M., Sabokro, M., & Fallahi, M. B. (2017). The ef-
fect of psychological capital on work engagement with mediat-
ing role of work-­f amily conflict among nurses. Quarterly Journal
of Nursing Management, 6(1), 20–­31. https://doi.org/10.29252/​
ijnv.6.1.20
Wang, H. F., Chen, Y. C., Yang, F. H., & Juan, C. W. (2021). Relationship
between transformational leadership and nurses’ job performance:
The mediating effect of psychological safety. Social Behavior
and Personality: An International Journal, 49(5), 1–­12. https://doi.
org/10.2224/sbp.9712
Weeks, S., Farmer, D., & Cohen, L. J. (2014). Transformational leader-
ship to promote interprofessional practice. International Journal
of Evidence-­ Based Healthcare, 12(3), 196–­205. https://doi.
org/10.1097/01.XEB.00004​55194.94174.34
World Health Organization. (2020). State of the world's nursing 2020:
investing in education, jobs and leadership. https://apps.who.int/
iris/bitst​ream/handl​e/10665/​33167​7/97892​4 0004​863-­ara.pdf
Xie, Y., Gu, D., Liang, C., Zhao, S., & Ma, Y. (2020). How transformational
leadership and clan culture influence nursing staff's willingness to
stay. Journal of Nursing Management, 28(7), 1515–­1524. https://doi.
org/10.1111/jonm.13092
Zurlo, M. C., Vallone, F., & Smith, A. P. (2020). Work–­family conflict and
psychophysical health conditions of nurses: Gender differences
and moderating variables. Japan Journal of Nursing Science, 17(3),
e12324. https://doi.org/10.1111/jjns.12324
How to cite this article: Labrague, L. J., & Obeidat, A. A.
(2022). Transformational leadership as a mediator between
work–­family conflict, nurse-­reported patient safety
outcomes, and job engagement. Journal of Nursing
Scholarship, 54, 493–­500. https://doi.org/10.1111/jnu.12756
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