The impact of transformational leadership on nurses’ job satisfaction and retention: a literature review

Mohmmad Othman   About the author: Mohmmad Othman, RN, MHM, PhD candidate, is a staff nurse in the intensive care unit at Christchurch Hospital, New Zealand. His correspondence address is [email protected] This article was accepted for publication in September 2022.	ABSTRACT Aim: The purpose of this literature review was to define the impact of transformational nursing leadership and its effect on nurses’ work satisfaction and retention. Background: Increasing nurses’ job satisfaction is one of the main ways of improving clinical outcomes, providing high-quality patient care and increasing the retention of nurses in health-care organisations. Methods: Six electronic databases were searched – PubMed, PubMed Central (PMC), Medline, Web of Science, Cochrane Library and EMBASE. Results: Thirty articles were included in the literature review after applying the inclusion and exclusion criteria. Findings: Nurses preferred leaders who displayed transformational leadership, and nurses who were more satisfied with their job were more likely to stay. The review findings underscored the value of the transformational leadership style for leading nurses and improving their job satisfaction and retention, and suggested the need for more commitment to teaching and improving positive leadership behaviour. Conclusion: Nursing managers should capitalise on the value of transformational leadership to increase the work satisfaction of nursing staff. It is unknown how nurse managers will establish valuable leadership skills, and so further study is required to identify strategies to improve effective leadership traits in nurse managers.
KEYWORDS transformational leadership, job satisfaction, retention, nursing turnover, leadership impact on nurses

INTRODUCTION

THERE IS A NEED for fundamental change across health-care organisations to create a work environment for nurses which is conducive to job satisfaction and wellbeing. Change is needed to the way leaders design the work, deploy personnel and align them to the organisational culture (Brown et al., 2013). Generally, these changes require nursing leaders to transform the physical work environment and the practices and beliefs of nurses in the workplace. This literature review aims to discuss and explain how nursing leadership can be important in transforming organisations, particularly in terms of the nursing workforce, to achieve efficient patient care and organisational goals.

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BACKGROUND

The literature shows there are many reasons for high nursing turnover. Among the significant reasons are job satisfaction, personal reasons, leadership style, the nature of the work environment, workplace stress, and other managerial and organisational factors (Currie & Hill, 2012; O’Brien-Pallas et al., 2010).

Transformational leadership is defined as the process of encouraging or motivating a group of individuals to work together towards a common objective. It can be described as guiding employees to realise a vision through a plan (Collins et al., 2019). A leader’s actions include a clear, long-term vision for the future and specific and unambiguous objectives that motivate subordinates to define their targets. In this sense, leadership is the process of inspiring others, particularly workers, to improve their abilities to achieve organisational success. Transformational leadership is a leadership style in which the leader recognises the need for change, develops a vision to drive the change through inspiration, and engages in positive behaviour to improve the commitment of the organisation’s members (Collins et al., 2019).

Leadership styles have been identified as an important factor in nursing leadership (Currie & Hill, 2012), and have been recognised as a crucial factor affecting quality of care (Havig et al., 2011; Sandström et al., 2011). Leaders’ qualities have also been directly associated with nurses’ intent to leave and the turnover of nurses (Roche et al., 2015). Therefore it is important that nurse managers adopt leadership styles that will reduce high nursing turnover and increase job satisfaction (Roche et al., 2015).

In a New Zealand study, Moloney et al. (2017) examined the reasons for nursing turnover to find out how to retain registered nurses (RNs) in New Zealand. This research found that nurses with supportive leaders were more satisfied with their work and were more likely to remain in their job. Many of the RN participants said they felt that successful leadership was a key factor in the retention of nurses. The nurses believed that managers needed to be passionate about what they did, and should share their expertise and talents, including a collective vision for supporting and improving nursing work roles (Moloney et al., 2017). A study conducted in New Zealand by North et al. (2012) concluded that the nurse turnover rate in New Zealand was 44.3 per cent over the 12-month period of data collection for their study. This rate is significantly higher than that of Canada (19.9 per cent), the United States (19.2 per cent) and Australia (15.1 per cent). However, North et al. identify limits in generalising this finding beyond the public hospital context of the study, given that the sample also included new-graduate nurses who contribute substantially to nurse turnover. Job strain, work/family conflict, a lack of control over work roles, a lack of rewards/recognition for their jobs, job complexity and the absence of team cohesion are all factors that contribute to nursing turnover.

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METHODS

A systematic database search was conducted to answer the following question: What is the impact of the transformational leadership style of nurse leaders on staff nurses’ job satisfaction and retention? The search was conducted from September to November 2020, with the following inclusion criteria: primary articles with full text available; written in English; and published within the last 10 years (2010-2020).

Information sources

Six electronic databases were searched: Medline, Web of Science, PubMed, PubMed Central (PMC), Cochrane Library and EMBASE. Thirty articles were eventually considered and retrieved from the databases for this study – 10 articles from PubMed, eight from PMC, five from Web of Science, five from Medline, one from EMBASE and one from Cochrane Library (see Table 1, below).

Table 1: Databases searched for relevant studies

Database	Relevant studies found	Data range for inclusion
PubMed	10	2010-2020
PubMed Central (PMC)	8	2010-2020
Medline	5	2010-2020
Web of Science	5	2010-2020
Cochrane Library	1	2010-2020
Embase	1	2010-2020
Total number of relevant studies	30

Inclusion and exclusion criteria

Studies were included if:

1. They were related to the effects of transformational leadership style on nursing staff’s job satisfaction and retention.
2. They were published between 2010 and 2020.
3. They related to other leadership styles, such as transactional or laissez-faire leadership, to compare the impact of different leadership styles on the nursing workforce.
4. They were primary (original research) or secondary (systematic literature review) research articles.

Studies were excluded if they were published before 2010 or were not published in the English language.

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FINDINGS

The findings of this review show how supportive nurse-manager leadership styles are associated with increased nurses’ job satisfaction and retention in health-care organisations (Abualrub & Alghamdi, 2012; Albagawi, 2019; Asamani et al., 2016; Banan, 2020; Cowden et al., 2011; Morsiani et al., 2017; Musinguzi et al., 2018; Suliman et al., 2020; Xie et al., 2017). Two key themes were identified in the literature: (1) the impact of nurse managers’ transformational leadership styles on staff nurses’ job satisfaction, and (2) the impact of nurse managers’ transformational leadership style on staff nurses’ job retention.

1. The impact of nurse managers with a transformational leadership style

The impact on nurses’ performance
Transformational leadership techniques of nurse managers have a significant impact on nurses’ performance. A study investigating the link between laissez-faire and transformational leadership (Albagawi, 2019) emphasises a significant positive relationship between nurse managers’ transformational leadership style and staff nurses’ level of satisfaction. Albagawi (2019) asserts that when nurse managers exhibit transformational leadership, staff nurses’ level of job satisfaction grows. As such, nurse managers that show a transformational leadership style are likely to impact their staff’s job satisfaction positively.

Leadership style and autonomy
The leadership techniques of nurse managers are critical to the job satisfaction of staff nurses. Considering the universal shortage of nurses, the rising cost of delivering health services, and increasing workloads, it is important to consider the types of nursing leadership styles (Asamani et al., 2016). Nurse managers use a variety of leadership styles, depending on the environment in which they work. Generally, staff nurses embrace supportive leadership techniques and participative leadership models (Asamani et al., 2016). Leadership style has significant implications for nursing management, education, practice and health policies. By finding a proper link between these factors, it is easier for nurse managers to enhance nurses’ job satisfaction.

Professional autonomy is a significant element of the role of nurses in patient care. It refers to the power to make judgments, and the freedom to act, based on one’s professional knowledge. Nurses in different parts of the world have differing perceptions of autonomy (Banan, 2020). The perception of many nurses regarding autonomy is that leaders can turn it on or off through their leadership styles. Banan (2020) argues that there is a need to incorporate autonomy into nursing practice, rather than practising it occasionally. Further, nurses need to have a broad perspective and to actively contribute to writing hospital policies and guidelines. These guidelines and policies need to recognise the importance of autonomy in the training and practice of staff nurses. A transformational leadership style can motivate nurses to deliver services autonomously.

Empowerment and leadership methods
As well as their influence on staff nurses’ job satisfaction, nurse managers showing transformational leadership also have an impact on patient safety. Improving patient safety is the key to effective leadership (Boamah et al., 2018). There is a strong positive correlation between transformational leadership and empowerment of staff nurses. Supportive leadership will increase nurses’ job satisfaction; therefore, it will improve patient outcomes. As Boamah et al. (2018) suggest, there is a link between job satisfaction and low adverse events in health care. For this reason, there is a need for managers to employ transformational leadership traits to create favourable conditions for job satisfaction and patient safety.

Nursing leadership has a significant impact on the satisfaction of nurses. According to Bormann and Abrahamson (2014), the style of nurse leadership determines staff nurses’ job commitment and hence their job satisfaction level. This finding suggests there is a need for both transactional and transformational leadership techniques in the training of nurse managers in the workplace.

Toxic leadership and quality working conditions
The transformational leadership style is highly associated with more positive nursing job outcomes. By contrast, toxic leadership, involving behaviours that are destructive or harmful to both organisations and individuals, is associated with nurse absenteeism, intentions of leaving the job, and decreased satisfaction in the workplace (Labrague et al., 2020). According to Labrague et al. (2020), health services’ strategies to retain nursing staff should include encouraging transformational leadership in nurse managers and eliminating harmful leadership practices. This can be done by preparing nurse managers for their role, providing them with evidence-based education and supporting their career development.

In the context of job satisfaction, nurses’ mental health status, job commitment, and commitment to the organisation are crucial factors. It is important to understand the potential positive impact of the model of transformational leadership on the quality of nurses’ working conditions. Work relationships affect nurses’ quality of life and well-being, and organisational-based factors have the potential to improve working life quality (Lin, 2015).

Long et al. (2014) investigated the correlation between staff nurses’ job satisfaction and transformational leadership. Long found that the transformational leadership style was one of the most effective leadership approaches, with useful leadership traits. The characteristics of an effective leader include the abliity to consolidate or command respect from their followers. They improve nurses’ job satisfaction by treating them as individuals. Transformational leaders act in a manner that stimulates and inspires their followers by providing them with meaning and challenge (Long et al., 2014).

Engagement and safe working
Engaging the nursing workforce is an essential technique for positively influencing their performance. Manning (2016) suggests that nurse managers who practice communication and support via transactional and transformational leadership have a significant positive impact on nursing engagement. There is also a relationship between nursing leadership styles and the safety of a working environment. Nurses need to be able to act autonomously in changing the working environment to enhance patients’ safety. Nurse managers should be strategically positioned to promote the effective and efficient operation of hospital services. As Merrill (2015) notes, transformational leadership is essential to promote change needed to provide a safe working climate.There is a need for nurse leaders to focus on growing these positive leadership traits to maintain a safe working environment.

Teamwork and motivation
Teamwork is another significant factor in nurses’ job satisfaction. Supportive leadership styles are crucial in instilling collaborative nursing practice (Negussie & Demissie, 2013). While it is not easy to master collaboration, transformational leaders understand that teams include a diverse range of people and resources, and they help staff develop and grow. Where there is team conflict, the influence of nurse leaders can make a difference. Team members usually come into conflict when they are competing with one another. Conflict leads to a lower level of team efficacy and a high level of negative emotion and distrust (Negussie & Demissie, 2013). As Negussie and Demissie note, transformational leadership is a significant factor in correcting team conflict in nursing.

Another study found the leadership style of nurse managers affected morale, motivation and staff retention (Musinguzi et al., 2018). The transformational leadership style has a significant positive influence on consolidating teamwork, stimulating motivation and creating job satisfaction. In contrast, laissez-faire leadership is characterised by passive behaviours such as lack of support or avoidance of situations, which can have a destructive effect on teamwork, and individual motivation and job satisfaction (Musinguzi et al.).

Emotional intelligence
There is a significant relationship between transformational leadership and emotional intelligence in nurse leaders, particularly in being able to manage relationships effectively. A descriptive exploratory study by Spano-Szekely et al. (2016) found that emotional intelligence correlated positively with transformational leadership among nurse managers in an acute care hospital. Outcome measures showed leaders are characterised by extra effort put into the leadership role, a higher degree of effectiveness and satisfaction in their role. There was also a positive relationship between transformational leadership techniques and advanced education in nursing management. Spano-Szekely et al. recommend that nursing administrators consider emotional intelligence when hiring nursing managers. They should also consider providing advanced education for nurse managers to help them develop the essential strategies for effective leadership.

Workplace wellbeing
Workplace wellbeing covers all aspects of an employee’s working life, from the quality and safety of the physical environment to how they feel about their job, as well as the workplace culture, atmosphere and conditions. One study investigating the impact of transformational leadership style on nurses’ wellbeing at work shows that using transformational leadership to look after nurses and increase their workplace wellbeing will lead to better job satisfaction (Abualrub & Alghamdi, 2012). Nurses who exhibited more job satisfaction had the intention to continue working at their job.

2. The impact of the transformational leadership style on staff nurses’ job retention

Creating a healthy environment
The leadership style of nurse managers increases staff commitment to an organisation and retention in the workforce (Kodama et al., 2016) through positive engagement in the workplace. Transformational leadership is responsible for motivating staff by creating a healthy work environment so staff are motivated even when the leader is not present. Nurse managers are aware of the different reasons for the lack of job satisfaction among nurses (Xie, 2017). Low job satisfaction can be caused by burnout or failure to be promoted, which can lead to nurses wanting to change career or retire. According to Xie (2017), the most common reason for job dissatisfaction is burnout. To improve job satisfaction and staff retention, nurse managers need to evaluate nurses’ workloads, develop succession plans and provide career counselling. Nurse managers are responsible for the formulation and creation of a healthy environment that promotes staff nurses’ job satisfaction and supports their professional nursing practice (Xie, 2017). Nurse managers’ level of perception and understanding of leadership techniques significantly improves nurse retention (Suliman et al., 2020). Hence, there is a need for nurse managers to undertake practical and theoretical training programmes on leadership to reduce nurse turnover and increase retention. In creating a leadership succession style, nurse executives in health services need to understand nurse managers’ satisfaction in their roles and their career aspirations.

Transformational components and retaining nurses
In terms of factors that affect nurses’ retention, research evidence shows that transformational leadership significantly affects employee functioning. Transformational leaders are capable of elevating and extending what staff are interested in and increasing staff commitment to their work and to the values of the organisation (Lavoie-Tremblay et al., 2016). They are capable of leading staff to go higher than their perceived interests. On the other hand, destructive or abusive leadership has a direct detrimental effect on staff commitment and organisational values.

Cowden et al. (2011) researched the relationship between nursing leadership practices and the intention of staff nurses to retain their current positions. The findings of this study show there is a need for management to focus on nurse retention and to understand what influences it. There was also a significant positive relationship between the transformational leadership style, retention of staff nurses and a supportive working environment (Cowden et al., 2011).

Nurse managers need to use evidence-based strategies to retain nurses in their organisations (Choi et al., 2016). They also require an understanding of nurses’ emotional responses to their work environment, ranging from joy at work to moral distress, which affects their desire to stay. Nurse managers’ perception and understanding of these issues are significant causal influences on nurses’ intention to remain in their job (Choi et al., 2016). In general, the transformational leadership style has a significant positive effect on a workplace, regardless of the number of hours staff work, the type of unit they work on, clinical experience or level of qualification (Lavoie- Tremblay et al., 2016).

Support and leadership education
Azaare and Gross (2011) found staff nurses were concerned about the leadership education of nurse managers, and that staff nurses wanted more constructive and coherent nursing leadership that promoted nursing autonomy. However, in this study, a significant proportion of nurse managers used minimal consultation in their managing of staff. Also, nurse managers were associated with the planning and implementation of weak policies, which led to staff nurses starting to lose trust in them and their job satisfaction declining.

This finding demonstrates the importance of ongoing education for nurse managers and other nurse leaders at all levels within health-care organisations (Amestoy et al., 2017). Amestoy et al. also emphasise the value of teaching the theory and practice of leadership at the undergraduate level prior to entry to practice so that graduates develop self-awareness to lead and know themselves as leaders, even as novice practitioners. While leadership is developed and strengthened over time, nurse lecturers and nurse managers are both important leadership role models for new graduates.

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IMPLICATIONS FOR PRACTICE

Nursing leaders should make a deliberate effort to prioritise learning as a core aspect of their everyday activities, and strive to embrace and express a transforming mindset. Many of the factors associated with staff retention can be managed or affected by nursing leadership. Nurse leaders play a vital role in changing the nursing profession by improving job satisfaction and staff engagement and fostering a healthier work atmosphere. When hiring nurse managers, nursing administrators could lead the way by working with human resources staff to consider the emotional intelligence of applicants. They must use their experience and awareness of the leadership skills nurse managers require to ensure that academic nursing programmes at all levels match the operational needs of today’s nursing leaders. They must use their experience and awareness of the leadership skills required by nurse managers to collaborate and teach academic nursing programmes that are related to the operational needs of today’s nursing leaders. They could also petition their organisations for time, money and funding for education for nursing leaders, to strengthen their practice of transformational leadership. Transformational leadership will increase the work satisfaction and commitment of the nursing workforce to the institution more effectively while facilitating the common growth of individuals and organisations. Further, it can also help to attract nursing staff by shifting organisational culture to be more inclusive and therefore enhance their willingness to stay.

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SUGGESTIONS FOR FURTHER RESEARCH

Future studies should explore the association between the specific components of transformational leadership and positive results to shed light on which behaviours are responsible for promoting the nursing workforce. Also, further research can explore how nurse managers can develop useful leadership characteristics. The theory of transformational leadership provides an exciting framework to investigate how nurse leaders can better promote nursing performance and job satisfaction.

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CONCLUSION

Health-care organisations are crucial social systems that put human resources at the forefront of their operations. Such entities require active employees and managers to attain the desired goals; thus, it is impossible to achieve success without their commitment and efforts. Leadership is central to this, since leaders are responsible for inducing followers to produce changes and also influence the nature of change. Effective and successful nurse managers are those that frequently demonstrate transformational leadership techniques. This type of leadership is positively linked with better job satisfaction among nursing staff and therefore better nurse retention. Nurses want better, proactive, independent and articulate leadership. An overview of some of the main ways by which transformational leadership increases nursing job satisfaction and retention is given in multiple key themes in this study. Overall, the findings of this literature review indicate that transformational leadership methods directly exercise their impact by encouraging nurse leaders and staff nurses to think about themselves and their tasks more positively, improving the quality of their relationships, and by building fair, respectful and welcoming work environments.

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