Linking Transformational Leadership to Patient Care Quality: The Role of Structural Empowerment and Nurses’ Clinical Leadership

Abstract

Background: Effective leadership is critical in driving and motivating registered nurses to provide high-quality patient care. Various researchers have established a link between effective transformational leadership in nursing and improved patient care outcomes, but it is unknown how this association is affected. Therefore, further research is needed to elucidate this mechanism of action. Aim: To examine the relationships between transformational leadership, structural empowerment, registered nurses’ clinical leadership, and patient care outcomes as perceived by registered nurses. Methods: This quantitative study used a cross-sectional, correlational design. It was conducted in a government tertiary hospital in Riyadh, Saudi Arabia, using cluster random sampling stratified by the nationality and gender of four subgroups of head nurses: Filipino (n=9), Indian (n=4), Saudi (n=12), and Jordanian (n=3). A total of 1,038 registered nurses were selected in clusters under each head nurse and were invited to participate. The study variables were assessed using the following instruments: 20-item Multifactor Leadership, 12-item Conditions of Work Effectiveness II, 15-item Clinical Leadership Survey, number and frequency of self-reported patient adverse events, and quality of nursing care. Data was analysed using SPSS Statistics for descriptive and multilevel analysis, and R for performing multilevel Structural Equation Modelling (MSEM). The study obtained ethical approval from both Queen’s University Belfast and King Saud Medical City. Results: A total of 664 surveys (response rate=70%) were analysed. The majority of registered nurse respondents were female (95%). The highest proportion of respondents were Indian (42.5%) and worked in critical care areas (36.3%). Most respondents were aged 30–35 years old (38.4%). The highest proportions of head nurses were female (67.9%) and Saudi (42.8%). The majority of respondents (52.7%) reported that their head nurses were frequently accessible, approachable, and visible in the clinical area. Overall, registered nurses reported high levels of transformational leadership (mean=3.01, SD=0.82), increased structural empowerment (mean=3.70/5, SD=0.73), high levels of clinical leadership (mean=4.07, SD=0.64), decreased patient adverse events (mean=1.47, SD=0.52), and a high quality of nursing care (mean=3.12/5, SD=0.51). Multilevel analysis showed a significantly positive association between transformational leadership and structural empowerment (β = 0.56, p < 0.001). Additionally, structural empowerment was positively associated with clinical leadership among registered nurses (β = 0.52, p < 0.001). Clinical leadership was positively linked to quality of patient care (β = 0.32, p < 0.001) and negatively associated with self-reported patient adverse events (β = −0.15, p < 0.001). Mediation analysis indicated a significant indirect effect of transformational leadership on clinical leadership through structural empowerment (B = 0.344, p < 0.001). Structural empowerment also had a significant indirect effect on self-reported patient adverse events through clinical leadership (B = −0.037, p = 0.003), and on quality of patient care through clinical leadership (B = 0.147, p < 0.001). Serial mediation showed a significant negative indirect effect of transformational leadership on self-reported patient adverse events through structural empowerment and clinical leadership (B = −0.044, p = 0.001), and a positive indirect effect of transformational leadership on quality of patient care through structural empowerment and clinical leadership (B = 0.101, p < 0.001). Ethnicity had a significant effect on transformational leadership (p=0.03) and the specialty unit of the head nurse played a notable role in shaping these perceptions across structural empowerment, clinical leadership, and quality of nursing care perceptions. The MSEM analysis showed a good model fit, supporting the hypothesised relationships between variables (CFI=.95, TLI=.95, RMSEA=.04, and SRMR=.06). These findings indicate that the model's constructs and their interrelationships align well with the collected data, supporting the study's conclusions. Conclusion: The study findings provided evidence of head nurses’ use of transformational leadership in creating an empowered nursing work structure and developing clinical leadership in registered nurses that promotes the overall quality of patient care by decreasing patient adverse events and delivering high-quality nursing care. Additionally, the research underscored the importance of recognising and addressing the influences of confounding variables, including gender, ethnicity, and specialty units. These factors shaped the dynamics between transformational leadership, structural empowerment, clinical leadership, and patient care outcomes. Healthcare organisations are thus encouraged to attentively confront these variables to promote more effective, inclusive, and equitable leadership practices. Such an inclusive approach is essential in empowering registered nurses to develop robust clinical leadership skills, enhancing their capacity to deliver superior patient care. Grounded in a cross-sectional design, this study offers an empirically based understanding of how transformational leadership functions in diverse nursing environments, providing a detailed and context-sensitive contribution to contemporary leadership practices and healthcare policy.