transformational leadership in healthcare literature review

• Open access
• Published: 08 April 2024

Transformational nurse leadership attributes in German hospitals pursuing organization-wide change via Magnet® or Pathway® principles: results from a qualitative study

• Joan Kleine   ORCID: orcid.org/0009-0005-1727-3683 1 ,
• Julia Köppen   ORCID: orcid.org/0000-0001-7941-641X 1 , 2 ,
• Carolin Gurisch   ORCID: orcid.org/0009-0008-3763-7220 3 &
• Claudia B. Maier   ORCID: orcid.org/0000-0002-7734-2258 2  

BMC Health Services Research volume  24 , Article number:  440 ( 2024 ) Cite this article

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Budget constraints, staff shortages and high workloads pose challenges for German hospitals. Magnet® and Pathway® are concepts for implementing organization-wide change and redesigning work environments. There is limited research on the key elements that characterize nurse leaders driving the implementation of Magnet®/Pathway® principles outside the U.S. We explored the key attributes of nurse leaders driving organization-wide change through Magnet®/Pathway® principles in German hospitals.

Using a qualitative study design, semi-structured interviews ( n  = 18) were conducted with nurse leaders, managers, and clinicians, in five German hospitals known as having started implementing Magnet® or Pathway® principles. The interviews were recorded and transcribed verbatim. Data were analyzed in Atlas.ti using content analysis. For the analysis, a category system was created using a deductive-inductive approach.

Five leadership attributes and eleven sub-attributes were identified as main themes and sub-themes: Visionary leaders who possess and communicate a strong vision and serve as role models to inspire change. Strategic leaders who focus on strategic planning and securing top management support. Supportive leaders who empower, emphasizing employee motivation, individualized support, and team collaboration. Stamina highlights courage, assertiveness, and resilience in the face of challenges. Finally, agility which addresses a leader’s presence, accessibility, and rapid responsiveness, fostering adaptability.

Conclusions

The study demonstrates leadership attributes explicitly focusing on instigating and driving organization-wide change through Magnet®/Pathway® principles in five German hospitals. The findings suggest a need for comprehensive preparation and ongoing development of nurse leaders aimed at establishing and sustaining a positive hospital work environment.

Peer Review reports

European hospitals are facing multiple challenges, including economic pressure, cost containment strategies, technological advancements, and shortages of healthcare professionals, which require constant adaptation [ 1 , 2 , 3 , 4 ]. Particularly concerning is the high burden of mental distress reported by nurses and other healthcare professionals [ 5 , 6 ]. It is increasingly recognized that the root causes of increased stress and burnout among nurses are linked to the work environment in hospitals and other healthcare settings, that is why hospitals should strive to change their working conditions [ 7 , 8 ].

The Magnet Recognition Program® (Magnet) and the Pathway to Excellence® Program (Pathway), both originating in the United States (U.S.) and held at the American Nurses Credentialing Center (ANCC), are designed to facilitate organizational-wide change of work environments, enhancing employee well-being, retention, productivity, and patient outcomes [ 9 , 10 , 11 ]. These concepts can provide a structured approach for European hospitals to tackle the challenges of the future effectively.

Research on Magnet hospitals, primarily conducted in the U.S., suggests that Magnet can enhance working conditions, job satisfaction, and nurse well-being in hospitals [ 12 , 13 , 14 , 15 ], while also improving patient outcomes [ 14 , 15 , 16 ]. However, findings across studies and outcomes vary. In contrast, the impact of Pathway has received less attention in research. Nevertheless, some studies have indicated that Pathway promotes increased nurse autonomy and decision-making authority, fosters leadership development, improves safety and quality standards, enhances employee well-being, and supports professional growth [ 17 , 18 ].

As of December 2023, 591 organizations worldwide had Magnet designation [ 19 ], and 214 had Pathway designation [ 20 ], with the majority in the U.S. Internationally, only 17 hospitals hold Magnet designation [ 19 ] and 16 have Pathway designation [ 20 ]. While none of them are in Germany, some German hospitals have proactively started implementing Magnet/Pathway principles to drive organization-wide changes aiming at enhancing job satisfaction, attracting and retaining healthcare professionals [ 21 , 22 , 23 , 24 ]. Hence, the inclusion of Magnet and Pathway principles as comparable case examples of organization-wide change in the current study is justified by the growing proactive adoption of these concepts by some German hospitals.

Magnet and Pathway focus on promoting nurse engagement and supporting professional nursing practice environments. The difference lies in their specific objectives: Magnet emphasizes sustained quality patient care, nursing excellence, and innovations in professional practice, while Pathway highlights creating supportive practice environments that empower and engage staff and is known for having less stringent data requirements [ 25 , 26 ]. However, both aim to cultivate a culture of nursing care excellence, supported by a transformational leadership style [ 25 ], which is the central focus of the present study.

Leadership skills do play a crucial role in successfully promoting organization-wide change [ 27 , 28 , 29 ] and has also been shown to have a profound impact on employee stress and emotional well-being [ 30 ]. Transformational leadership was identified as one effective leadership style in healthcare settings [ 29 , 31 , 32 , 33 ]. Transformational leaders motivate employees towards an organizational vision by inspiring and empowering them to continuously develop themselves and addressing their individual needs [ 34 , 35 ]. The theoretical framework for transformational leadership was first conceptualized in the 1970s, defining it as a relationship between leaders and employees who motivate, empower, and elevate each other’s moral values in pursuit of fulfilling common interests [ 36 ]. Further expansion by Bass and Avolio introduced four subcategories that represent the characteristics of transformational leaders: Idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration [ 34 , 35 ].

Several U.S. studies have analyzed the relationship between transformational leadership and the implementation of Magnet principles [ 37 , 38 , 39 ]. In a southern U.S. nonprofit acute care hospital seeking Magnet designation, a survey of 115 staff nurses showed that transformational leadership style was positively associated with nurses’ job satisfaction and satisfaction with promotion opportunities [ 37 ]. Magnet hospital CNOs rated their transformational leadership practices highly and reported a strong positive correlation between engagement and leadership practice, with empowering others as the most important practice [ 38 ]. A study of clinical nurse leaders, who attended the 2016 Magnet Conference in Orlando, Florida, showed a positive relationship between transformational leadership practices and work engagement, but observed differences in leadership practices and work engagement based on varying levels of education [ 39 ].

The majority of research conducted outside of the U.S. has focused on investigating the impact of transformational leadership style within healthcare settings, with no focus on the implementation of Magnet/Pathway [ 29 , 31 , 32 , 33 , 37 , 40 , 41 , 42 , 43 , 44 , 45 ]. Several studies found that forms of transformational leadership styles resulted in positive organizational performance, such as improved staff retention, lower turnover, and better quality of care [ 31 , 32 , 33 , 37 , 40 , 41 ]. A systematic review including 12 studies from the US, Canada, Saudi Arabia, China, Ethiopia, Italy, and Jordan, showed a positive correlation between transformational leadership and nurses’ job satisfaction in the hospital setting [ 29 ].

To date, most of the qualitative studies analyzed transformational leadership style from the nurse leaders’ perspective. A study from Finland used a qualitative design to examine nurses’ leadership skills in leading change [ 44 ]. They identified three main roles: First, ‘leading interpersonal relationships’ including competencies of being a team player, coach, and parental figure. Second, ‘leading processes’ including competencies such as organizing, coordinating, and being a conductor based on the organization’s mission. And third, ‘leading a culture’ is defined as advocating values and norms and creating an open, resilient, and evidence-based culture [ibid.]. Another study from 2016 explored senior nurses’ experiences of organization-wide change leadership in three NHS acute hospitals in England through in-depth interviews [ 43 ]. The aspect of leadership was frequently discussed in relation to organization-wide change. An effective nurse leader was characterized as a strong, inspiring, and supportive leader with novel and heroic approaches [ibid.]. Weak leaders were those who did not encourage their teams, had poor presence and were unresponsive to the need for change [ibid]. Another qualitative study used a grounded theory approach to examine the processes nursing management uses to promote change on their wards in five hospitals in Japan [ 45 ]. According to the interviewees, the change management process led by nurse managers consists of having beliefs and being able to empathize with the nursing staff to achieve common goals [ibid.]. Four characteristics of nurse leaders were reported as indispensable factors for change: having both a micro and macro perspective; respecting their own beliefs and external standards; being proactive; having empathy for nursing staff [ibid.]. A 2020 study conducted in a university hospital in Brazil, examined the challenges of exercising transformational leadership and strategies nurses leaders used to address these challenges include being role models for the team, proactively maintaining dialogue with co-workers, and building empathetic relationships [ 42 ].

In German hospitals, a cross-sectional study investigated nursing leadership styles, analyzing the self-assessment of 93 ward managers and the external evaluation of 1,567 employees with the multifactorial leadership questionnaire (MLQ-5X), revealing the presence of transformational leadership practices [ 46 ]. The ward management consistently achieved mean values above the scale mean in all dimensions of transformational leadership, both in the self-assessment and in the external evaluation [ibid.]. However, despite the acknowledged existence of transformational leadership practices in nursing within German hospitals, research on the attributes of nurse leaders that support organization-wide change through implementation of Magnet/Pathway principles remains scarce. This study aims to identify beneficial attributes of nurse leaders from German hospitals, shedding light on their role in driving organization-wide change through Magnet/Pathway and advancing the understanding of leadership practices’ impact within the German healthcare systems. Research on this topic is critical to fill a gap in the literature regarding nurse leader attributes that facilitate organization-wide change and can provides insights that could inform nursing leadership development initiatives tailored to the needs of German hospitals seeking Magnet/Pathway designation.

Design and setting

This study was conducted as part of the German Magnet pioneer study, based on a qualitative research design in five pioneer hospitals. Semi-structured interviews were conducted between March and October 2020 with nurse leaders, managers, and clinicians involved in introducing Magnet or Pathway principles in five German hospitals. Inclusion criteria were as follows: (i) hospitals known as pioneers, defined as early adopters of the Magnet or Pathway principles, (ii) having started the implementation on their own initiative prior to 2020. For the purposes of this study, the primary focus was on the leadership attributes of nurses driving organization-wide change using Magnet/Pathway principles. The research protocol was approved by the Ethics Committee of the Charité (No. EA4/185/19). This study used the consolidated qualitative research reporting criteria (COREQ) [ 47 ].

The semi-structured interview guide contained a total of nine question with a set of probing questions. Topics covered motivation and rationale for implementing Magnet/Pathway, the identification of facilitators and barriers, of which one question was specifically on the role of leadership. However, interviewees referred to leadership attributes and practices throughout the interview in various instances. All interviewees filled out a short questionnaire on demographic characteristics and information about their role in the hospital, position, and years of work experience.

Sample recruitment

The purposive sample consisted of 18 persons from the five hospitals. Hospital size ranged between 200 and 2000 beds. Interviewees were nurse leaders, managers, and clinicians who had gained experience with the implementation of Magnet/Pathway. All requested interview partners agreed to be interviewed.

Data collection and analysis

Interviews were conducted in German and face-to-face by three members of the research team, following the semi-structured interview guide. The interviews lasted between 30 and 135 min. The interviews were anonymized and transcribed verbatim and were coded with ID01-ID18. The analysis of the anonymized transcripts was carried out in a multi-stage procedure based on content analysis, with a content structuring and summarising approach according to Mayring [ 48 ].

A deductive-inductive approach was chosen. The transcripts were coded using the data analysis software ATLAS.ti. For the deductive coding a coding guide was developed prior to the analysis based on the five components of the Magnet model [ 10 ]. Subsequently, the content of the deductive code leadership was re-analyzed in-depth inductively to answer the research question.

Several measures were applied to ensure transparency and quality. This involved investigator triangulation whereby the three researchers were involved in the data collection, analysis, and interpretation of the study [ 49 ].

Prior to the interviews, the three researchers conducted pilot interviews among themselves to ensure consistency. The coding of the interviews was performed by the three researchers who also conducted the interviews. Each coder was familiar with all 18 transcripts. After a pilot analysis phase with three interviews which were coded together and discussed at length to achieve high interrater agreement, the transcripts were randomly allocated. In regularly scheduled meetings, the coders reported the interim status and discussed problems or questions regarding the analysis and reviewed sample content of the codes together. In the next step, themes and sub-themes were formed by the researchers and discussed. Examples of quotes from interviewees are provided in the results section to enhance understanding of the interpretation of the results.

Interviewee characteristics

The 18 interviewees had a mean age of 48.9 (SD: 10.0) years, seven were female and eleven male. The majority ( n  = 16) had a degree in nursing and two a degree in medicine. Leadership and/or staff responsibilities had 17 interviewees and on average they had five (SD: 2.8) years of experience with implementing Magnet/Pathway (see Table  1 ).

All 18 transcripts were included in the analysis, regardless of whether direct quotes are shown in this study. Five main leadership attributes (subsequently referred to as main themes) driving organization-wide change using the Magnet/Pathway principles were identified: visionary, strategic, supportive, stamina, and agility. The main themes consist of eleven sub-themes (see Table  2 ).

Main theme 1: Visionary

Two sub-themes were clustered as the main theme visionary. It emerged that having a vision and acting as a role model were identified as requirement to implement organization-wide change.

Having a vision

Most interviewees agreed that leaders need a vision that they carry with conviction and strive to realize with high motivation. Interviewees suggested that a leader who is visionary would inspire employees for the change process. Furthermore, some interviewees mentioned that it is beneficial if leaders communicate well their vision of the future to their employees.

“With a vision I can inspire people. So, I need something that is strong enough, that really radiates energy, that […] gives people courage.” (ID9) .

It was seen as essential that the visions should be catchy, based on clinical practice and reflect the needs of clinical practitioners. One of the interviewees also mentioned the involvement of employees in the practical elaboration of the vision.

“So, I […] presented the vision to my team. […] And we went into working groups on how we can implement it, how we can live it. We have three keywords in there: human, competent, pioneering.” (ID14) .

The interviewees described the need for people who serve as role models that adhere to their vision, ideals, and values and stand up for them. Leaders acting as role models were identified as being less concerned with fulfilling specific criteria for maintaining a label or certificate but focused on improving the well-being of employees and quality of care. Interviewees explained a role model function of leaders as beneficial when employees could identify with their leaders, as this makes it easier to formulate and accept the vision and values as common goals. One interviewee stressed the importance of the personality of the leader and their manner of communicating with their staff.

“I would almost reduce it to the personalities that drive the whole thing. So, it always depends on how you transmit something, how do you communicate, how do you deal with your staff.” (ID4) .

A role model as an inspiration was suggested to increase the motivation of the employees to develop themselves and eventually to work towards the achievement of common goals.

“For me it was […] exciting to have a nursing director who brought special knowledge and an enthusiasm that I sometimes missed in the nursing field. […] just ahead of the times and […] powerful with motivation and of course that caught me.” (ID2) .

Main theme 2: Strategic

Two sub-themes were identified under the main theme strategic: Critical attributes as strategic planning and convincing top management contribute to effective implementation of positive change.

Strategic planning

Interviewees mentioned that leadership attributes included the ability to plan strategically to meet the goals of the hospital. For example, one of the interviewees described that the implementation of transformational leadership had been the key to driving further changes in the direction of Magnet.

“I think that the key component to live the Magnet concept is transformational leadership. […] I first must manage through leadership to keep people and attract new ones. And if that succeeds, […] then I can bring the other components into life […].” (ID9) .

Some interviewees highlighted the relevance of strategic resource allocation to be able to initiate and sustain the hospital-wide change via Magnet/Pathway principles. This included investing in human resources, e.g. nursing scientists or project coordinators, and in structural development, e.g. data management or digitalization. One interviewee described the strategy of providing budget or other cost-related information for the top management and the board required for Magnet/Pathway implementation.

“There needs to be at least […] an overarching Magnet project manager or director. […] last year I made an initial rough calculation for the board […] as a template, what it would cost the hospital. […] because that is of course indispensable.” (ID7) .

Convincing top management

Most interviewees addressed the importance of seeking and gaining the support of top management to advance change processes.

“The first step, […], was to convince the executive director, because the combination is simply necessary to do anything at all.” (ID4) .

One interviewee underscored the importance of active involvement and dedication from top-level decision makers and management in driving organization-wide change processes.

“So, I think you definitely need […] - the decision makers, the management - they must commit themselves clearly to it, and they must have a vision in this direction […].” (ID5) .

Main theme 3: Supportive

Three sub-themes were clustered under the main theme supportive. To be a supportive leader who fosters an empowering workplace to meet Magnet/Pathway principles, it was described as important to inspire and motivate employees to evolve professionally, support employees individually in developing themselves and their ideas further and cultivate a strong team spirit as a team player to pursue common goals.

Inspiration and motivation

Some of the interviewees talked about encouraging and inspiring employees to go beyond themselves. Increasing employees’ self-confidence enabled them to make their own decisions and motivated them to evolve professionally. This increased the motivation to drive positive change within the organization. One of the interviewees further explained that the higher the motivation in the team, the faster positive changes could be implemented.

“The half of it is […] that you get moving forward and, of course, the more motivated you are, the faster and the better you get moving forward. So, it’s about strengthening motivation and this for the whole team and making sure that you get better professionally.” (ID2) .

A leader should have a passion for the intended changes to persuade and motivate all employees and should take into account the time component of implementing organization-wide change using the Magnet/Pathway concept.

“And you have to be passionate about the topic, otherwise the concept won’t work either. That takes time at first. And then the biggest task is to get all the employees on board.” (ID4) .

Individual support of employees

The individual support of employees by leaders was recognized as indispensable when it comes to empowering them. According to the interviewees it was important to create a trusting working environment and to make employees feel that they are supported in developing themselves and their ideas further.

“[T]he employees must feel something is getting better for me. Managers are standing up for me, they are behind me. That is what is important for employees.” (ID9) .

However, finding the right support for each employee required individual consultation. Only in this way special circumstances and needs could be considered in a targeted manner. In particular, support for the academic training of bedside nurses is mentioned by interviewees as an example which underscores the significance of management’s role in facilitating and encouraging such endeavors.

“[…] there was […] a young [male nurse] sitting there […] who says, ‘Yeah, did I get this right, you want us all to have academic degrees?’ And he says, ‘Listen, I’m 35, I have three kids, I can’t afford to give up one euro right now at all.’ And [the CNO] understands, of course, there are priorities. But then you must see how you can support someone like that. […] If someone wants the [bachelor in nursing] […] then there is massive support, especially at the management level.” (ID7) .

Team player

The interviewees shared the idea that inspiration, motivation, and support of staff succeed more effectively when leaders are perceived as team players. According to the interviewees, a strong team spirit strengthens motivation to pursue common goals and helps not to give up. It also supports the well-being of all employees in their daily work.

“The team spirit is so important because if you motivate a team, if you win a team, and if you, as the leader of such a team, ensure that people enjoy working together and that the day-to-day problems can be sorted out, and if it says at the top and at the front: We are a team, we do this together, and together we are strong, Then you have already won half of everything that can be won.” (ID2) .

An interviewee at a higher managerial level additionally stated that it is important to always maintain a friendly atmosphere and show appreciation to receive important information about current issues and concerns in the teams. Decisions should not be made alone, but should always be considered with the teams, as they know more about the day-to-day matters of the staff members.

“We have […] a very, very friendly interaction, because I think that they are not my subordinates, they are my ward managers and they are the most important source of work for me, so to speak. Without them, I wouldn’t need to show up here to work, without my ward managers interacting with their teams, knowing exactly what’s going on here right now […], where’s the tension right now? What’s going well right now, what’s not going well right now?” (ID17) .

Main theme 4: Stamina

Two of the sub-themes were clustered as the main theme stamina. It emerged that implementing organization-wide change requires leaders who have strong personalities with courage and assertiveness.

The interviews showed that courage and a willingness to take risks in a context of uncertainty, which requires change, is experienced as a beneficial leader attribute. For the interviewees, courage meant being committed to the community and pursuing a vision and goals and being persistent about them. The step of opting for the implementation of organization-wide change with the Magnet/Pathway is described by some interviewees as a dare and leaders should be prepared for negative effects and to face resistance.

“I would say: Yes, you can always change something. And I didn’t let myself be discouraged […]. Sometimes people have said that we can’t really implement the Magnet concept here. And for me it was always important which ideas from the concept can be implemented and this I want to implement […], but I don’t let that stop me. […] And of course you also need leaders who are strong enough to say: ‘I know, even if it sounds crazy, we’re going in that direction now’.” (ID9) .

Nevertheless, especially in times of nursing shortages and high workload, it was important to have a sense of achievement to summon up courage. One of the CNOs interviewed reported that due to a high number of applicants to study nursing in the interviewee’s initial phase at the hospital, the interviewee had gained the courage to believe in the change concept and continued to pursue the interviewee’s vision despite high workloads and poor moods among the nursing staff and continued to pursue their vision.

“[…] despite reports of work overload, which reached me in droves at that time in my starting phase […], and then I was talking about academic training, actually I almost got a slap in the face, but at the same time [many] applied [to study nursing]. And then that was again the point where I had confidence: ‘You’re sticking to it; you have the courage’.” (ID3) .

Assertiveness

Interviewees agreed that implementing organization-wide change requires a high level of commitment and that leaders should have assertiveness. It was mentioned that it is important to prepare for the long term and to be aware of the length of time required to drive change processes using the Magnet/Pathway concept.

“I think the concepts themselves are very, very complex and take an incredible amount of time to implement. But it is possible. You just need someone who has stamina and who stands there and says, ‘So, and I want this, and this is the way, and this is my way, and I’m going to follow through.‘” (ID14) .

A sufficient individual resilience of leaders in hospitals was described as crucial to be able to overcome past failures, learn from them and stay positive. An interviewee described that initial rejection of new intervention plans by employees was initially perceived as a setback, but the leaders remained strong and learned from it.

“Well, that certainly took its time. [The CNO] came back [from U.S.] to the hospital with lots of new ideas and everyone who hears something new first says: ‘Stop, hold this. […], English words, now we only use English words. What does Magnet mean at all?’ and there was already a lot of distance from the employees […]. But then [the CNO] was able to convince […] at least the mangement level.” (ID4) .

Convincing top management was also described as an endeavor and requires the attributes of assertiveness and courage. One example is to advocate for one’s employees.

“And my job as a CNO, of course, is to fight to make sure that my nurse leaders have the resources, from time, to space, to other things, to be able to do good leadership.” (ID9) .

Main theme 5: Agility

In the context of this study, agility means the ability to adapt flexibly and quickly to changing tasks, circumstances, and demands as well as fostering a sense of team spirit. Two of the sub-themes were clustered as the main theme agility; showing presence and demonstrate well and fast accessibility and responsiveness.

Showing presence

It emerged from the statements of the interviewees that showing presence and direct personal contact of the leaders towards the employees was an important competence to keep up the commitment of the employees for implementing positive change within the hospital.

“Of course, I’m also in favour of the director of nursing not working at the bedside anymore […], but they should also not forget the direct contact to those who do the frontline work.“(ID2) .

With personal presence the leader’s appreciation of frontline workers and the interest in their well-being could become more tangible. It would also be a better way to transmit enthusiasm for the overarching, common goal to employees. Likewise, communication lines would be shortened, and employee concerns and needs could be addressed quicker. One of the interviewees shared a key moment when the CNO introduced himself unannounced at a staff meeting, and this sparked a sense of optimism among the employees.

“And I don’t think there’s ever been anything like this before, where a team meets for a dialogue and all of a sudden the CNO comes in and introduces himself and also says something about his philosophy and how he would like it to be. […] And that was the first jolt, because the employees realized, there’s someone who’s not untouchable, but there’s someone who’s like us.” (ID14) .

Another interviewee stated that they were expected as a nurse leader to know as many of the employees personally as possible. This was an essential factor for equal interaction between the professional groups.

“I know a lot of our nurses […], I know all the academic nurses, […] people expect me to take an interest in them. The whole eye-level system means that you really give everyone a name as well, not just a number anymore.” (ID1) .

One of the interviewees acknowledged that a lack of presence at the frontline work, as well as a lack of interest in the processes by the leader, had negatively impacted the success of implementing change processes.

“He [CNO] wasn’t on the wards; he didn’t see that as his responsibility either. It was more like; he gives the strategy and then the others are supposed to do the implementation. That just didn’t work out well. […] it was certainly a barrier that the [CNO] had little understanding of the daily operational problems. […] It would still have been easier if the employees had experienced him as being a little closer to the employees.” (ID10) .

Accessibility and responsiveness

In addition, interviewees explained that by showing presence outside of their own office, leaders should also cultivate an “open door”-culture and be available to meet with employees at short notice. This includes accessibility via various communication channels but also quick responsiveness.

“My door is open all day. I am not the leader who is available once a year for one hour […], but I am permanently there for dialogue, I do have time.” (ID6) . “We do a topical hour with the nursing directorate where they can come and get in touch with science here. [AND] Cappuccino with the nursing directors; where everyone can come without an appointment and also have individual talks […].” (ID3) .

Another interviewee used a current occurrence to stress the importance of responding to employee requests as soon as possible to keep them motivated.

“Right before you came in, there was a colleague who asked me […] if he could do a work shadowing. Within three minutes he got his answer […]. What use has a rigid structure, if you let someone like him wait for two weeks and say ‘Well, I was overworked’? You have to address these things.” (ID2) .

The findings of this study shed light on the attributes of nurse leaders in German hospitals that drive organization-wide change using Magnet/Pathway, which are aimed at improving employee well-being, productivity, and patient outcomes. A key component of the concepts is the practice of transformational leadership [ 9 ]. The results highlight five main themes that encompass beneficial leadership attributes: visionary, strategic, supportive, stamina, and agility.

The theme of visionary underscores the significance of visionary leadership in driving organization-wide change towards Magnet/Pathway. Having a clear and compelling vision that is communicated effectively to employees emerged as a key factor. The role of leaders as role models who embody vision and values was also emphasized. This aligns with existing literature on transformational leadership, which emphasizes the importance of idealized influence and inspirational motivation [ 34 , 35 ]. Leaders who serve as role models and inspire others create a sense of identification and motivation among employees to work towards common goals.

The theme of strategic highlights the role of strategic planning and resource allocation in Magnet/Pathway implementation. Several studies confirmed that strategic thinkers are among the most effective leaders. People with the ability to think strategically are more likely to ensure the sustainable success of an organization and are better able to put existing strategic plans into execution [ 50 , 51 , 52 , 53 ]. Furthermore, this study emphasizes the importance of leaders advocating for Magnet/Pathway principles to gain the support and commitment of the top management. Convincing the top management was seen as crucial for the success of change efforts.

The supportive theme emphasizes the significance of individualized support for employees’ development and well-being. This includes empowering employees to pursue further education, addressing their unique needs, and fostering a trusting work environment. This study highlights the role of leaders in providing resources and support for academic advancement, which aligns with the Magnet key component on structural empowerment. Furthermore, the importance of team spirit and collaboration was emphasized, echoing the Magnet/Pathway principle of exemplary professional practice and a collaborative work environment. Supportive leaders act as team players and inspire and motivate their staff to perform beyond the norm [ 38 , 54 ]. They support staff nurses to assessing their own performance, working out their goals and defining their responsibilities [ 38 , 43 , 44 ]. As a result, nurse leaders can promote knowledge building, intrinsic motivation and innovative work behavior among nurses [ 54 ].

In the German healthcare system, it is noteworthy that not every nursing director automatically holds a position on the hospital’s executive board, underscoring the importance of engaging top management in organizational change initiatives. Additionally, given that lifelong learning and continuous professional development are not standard practices in nursing in Germany, contrasting with the conditions required for Magnet/Pathway implementation, it highlights the crucial role of CNOs in empowering their staff and fostering a culture of lifelong learning and professional growth.

Results of previous qualitative studies analyzing transformational leadership style from the nurse leaders’ perspective confirm these findings. They include competencies such as a strong, inspiring, and supportive leader with novel approaches. The leaders serve as role models and are able to empathize with nursing staff to achieve common goals [ 42 , 43 , 44 , 45 ]. By cultivating a visionary outlook and a supportive stance, nurse leaders can effectively foster work engagement, address burnout, and create a motivating environment for healthcare professionals. Importantly, these leadership qualities can be learned and improved over time among nurses through targeted educational interventions, training, mentoring, and hands-on experiences [ 55 , 56 , 57 ]. Nevertheless, while some leadership skills can be developed through training and experience, certain innate character traits may provide an inherent advantage in the cultivation of effective leadership [ 58 ]. For instance, personality traits such as emotional intelligence, empathy, and authenticity have been linked to leadership effectiveness [ibid.]. Although these traits may not be directly teachable, they may serve as foundational elements that contribute to the development of successful transformational leadership practices.

The alignment between the findings of this study and those from various international contexts raises important implications for both the Magnet/Pathway implementation process and the broader understanding of transformational leadership. The resemblance between the identified leadership attributes and those found in studies conducted in different countries suggests a level of universality in the leadership qualities required for successful organization-wide change, particularly in healthcare settings. Furthermore, the consensus between the leadership attributes identified in this study and those from international research may imply that studies solely focused on transformational leadership can offer relevant insights for organizations pursuing Magnet/Pathway designation.

Given the diversity of leadership approaches across other sectors (including industry), it is important to recognize the contextual relativity of specific leadership traits. While the leadership attributes identified in this study are tailored specifically to nursing within hospitals, they may be relevant in other sectors, but require further evaluations in different contexts. While a leader’s ability to communicate a clear vision and motivate employees is as crucial in the business sector as in healthcare, the best way of communication and motivation may vary.

New insights that expand the understanding of the role of leadership in driving organization-wide change that emerge from this study is the perspective on the themes of stamina and agility in the context of transformational leadership and Magnet/Pathway implementation.

The theme of stamina reflects the perseverance and resilience required for implementing Magnet/Pathway principles. Leaders need courage to navigate uncertainty and take calculated risks. Leaders should want to make changes and push them forward with stamina and assertiveness, and who are not afraid to speak up and ask for support from higher authorities. In the context of transformational leadership, stamina has often been discussed as a leader’s perseverance, determination, and resilience in the face of challenges [ 34 ]. However, the findings of this study emphasize a more profound dimension of stamina as the leader’s ability not only to persevere, but also to inspire and sustain momentum during complex, long-term endeavors such as Magnet/Pathway implementation.

The concept of agility as an essential leadership skill has gained attention in recent years and refers to a leader’s ability to adapt quickly to changing circumstances. This aligns with the dynamic nature of healthcare settings, where leaders must respond to changing demands [ 59 ]. Interviewees in this study emphasized the positive impact of agile leadership, which enables leaders to respond rapidly, purposefully, and individually to different situations [ 59 , 60 , 61 ]. By adapting task structures and difficulty levels to match employees’ needs and commitment, leaders can prevent both under- and over-challenging their team members, thereby facilitating their professional development [ 59 , 60 , 61 ]. With the sub-themes showing presence as well as accessibility and responsiveness, it became clear that leaders should be in regular exchange with their employees to be able to react agilely to the requirements and needs [ 62 ]. In contrast, the findings confirm that the lack of frontline presence as well as the leader’s lack of interest in the processes negatively impacted the success of Magnet/Pathway implementation. However, in the context of Magnet/Pathway implementation, agility goes beyond flexibility to include a dynamic responsiveness to evolving healthcare challenges. The results show that leaders need to be flexible not only in their decision-making, but also in their accessibility and responsiveness to employees. This reflects a proactive approach that not only supports the implementation of the Magnet/Pathway principles, but also ensures that employees remain engaged and motivated throughout the transformation process.

Limitations

This study has several limitations. Firstly, the interviews were conducted in only five German hospitals, yet they were the first ones known to have started introducing Magnet or Pathway in Germany. While these hospitals provided valuable insights into the implementation process, the perspectives shared by leaders and staff are not representative of all hospitals in Germany, limiting the generalizability of the findings. Secondly, the majority of interviewees in this study were nurse managers or individuals with leadership responsibilities. As a result, the findings primarily reflect the management and leadership perspective, potentially overlooking the viewpoints and experiences of frontline nurses. It is important to consider a wider range of perspectives to gain a comprehensive understanding of the challenges and opportunities associated with leadership while implementing Magnet/Pathway principles.

This study provides in-depth insights into the leadership attributes that drives the implementation of organization-wide change through Magnet/Pathway principles in German. It offers guidance for nurse leaders seeking to drive positive organization-wide change and enhance employee well-being.

The interviewees in this study emphasized the importance of leadership competencies such as visionary direction, strategic planning, personalized support, resolute stamina, and adaptive agility. The themes of stamina and agility offer new insights, showcasing the need for courage, assertiveness, and adaptability in leaders driving long-term organization-wide change towards Magnet/Pathway.

Given the vital role of transformational leadership in driving organization-wide change, as well as the fact that transformational leadership skills can be trained, a comprehensive preparation and ongoing development of nurse leaders toward transformational leadership skills may support establishing and sustaining a positive work environment in hospitals.

Data availability

A 32-item checklist for interviews and focus groups (COREQ) and the coding tree are provided as supplementary material. The transcripts used and analyzed during the Magnet pioneer study are available from the corresponding author on reasonable request.

Abbreviations

American Nurses Association

American Nurses Credentialing Center

Chief Nursing Officer

Consolidated Criteria for Reporting Qualitative

Interviewee Identification

Multifactor Leadership Questionnaire

National Health Service

Standard deviation

United Sates of America

Rafferty AE, Griffin MA. Perceptions of organizational change: a stress and coping perspective. J Appl Psychol. 2006;91:1154–62. https://doi.org/10.1037/0021-9010.91.5.1154 .

Article   PubMed   Google Scholar  

Duncan S, Rodney PA, Thorne S. Forging a strong nursing future: insights from the Canadian context. J Res Nurs. 2014;19:621–33. https://doi.org/10.1177/1744987114559063 .

Article   Google Scholar  

Alonso JM, Clifton J, Díaz-Fuentes D. The impact of New Public Management on efficiency: an analysis of Madrid’s hospitals. Health Policy. 2015;119:333–40. https://doi.org/10.1016/j.healthpol.2014.12.001 .

Nilsen P, Seing I, Ericsson C, Birken SA, Schildmeijer K. Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses. BMC Health Serv Res. 2020;20:147. https://doi.org/10.1186/s12913-020-4999-8 .

Article   PubMed   PubMed Central   Google Scholar  

Kim M-S, Kim T, Lee D, Yook J-H, Hong Y-C, Lee S-Y, et al. Mental disorders among workers in the healthcare industry: 2014 national health insurance data. Ann Occup Environ Med. 2018;30:31. https://doi.org/10.1186/s40557-018-0244-x .

Skoda E-M, Teufel M, Stang A, Jöckel K-H, Junne F, Weismüller B, et al. Psychological burden of healthcare professionals in Germany during the acute phase of the COVID-19 pandemic: differences and similarities in the international context. J Public Health. 2020;42:688–95. https://doi.org/10.1093/pubmed/fdaa124 .

Nowrouzi B, Lightfoot N, Larivière M, Carter L, Rukholm E, Schinke R, Belanger-Gardner D. Occupational Stress Management and Burnout Interventions in nursing and their implications for healthy work environments: a Literature Review. Workplace Health Saf. 2015;63:308–15. https://doi.org/10.1177/2165079915576931 .

West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388:2272–81. https://doi.org/10.1016/S0140-6736(16)31279-X .

ANCC. 2023 MAGNET Application Manual; 2021.

Magnet Model ANA. 2017. https://www.nursingworld.org/organizational-programs/magnet/magnet-model/ . Accessed 19 Mar 2023.

Pabico C, Cadmus E. Using the pathway to Excellence® Framework to create a culture of sustained Organizational Engagement. Nurse Lead. 2016;14:203–6. https://doi.org/10.1016/j.mnl.2016.01.005 .

Kelly LA, McHugh MD, Aiken LH. Nurse outcomes in Magnet® and non-magnet hospitals. J Nurs Adm. 2012;42:S44–9. https://doi.org/10.1097/01.NNA.0000420394.18284.4f .

Kutney-Lee A, Stimpfel AW, Sloane DM, Cimiotti JP, Quinn LW, Aiken LH. Changes in patient and nurse outcomes associated with magnet hospital recognition. Med Care. 2015;53:550–7. https://doi.org/10.1097/MLR.0000000000000355 .

Petit Dit Dariel O, Regnaux J-P. Do Magnet®-accredited hospitals show improvements in nurse and patient outcomes compared to non-magnet hospitals: a systematic review. JBI Database Syst Rev Implement Rep. 2015;13:168–219. https://doi.org/10.11124/jbisrir-2015-2262 .

Rodríguez-García MC, Márquez-Hernández VV, Belmonte-García T, Gutiérrez-Puertas L, Granados-Gámez G. Original Research: how Magnet Hospital Status affects nurses, patients, and organizations: a systematic review. Am J Nurs. 2020;120:28–38. https://doi.org/10.1097/01.NAJ.0000681648.48249.16 .

McHugh MD, Kelly LA, Smith HL, Wu ES, Vanak JM, Aiken LH. Lower mortality in magnet hospitals. Med Care. 2013;51:382–8. https://doi.org/10.1097/MLR.0b013e3182726cc5 .

Hume L, Hall M. Sustaining a positive practice environment after pathway to Excellence® designation. Nurs Manage. 2020;51:6–9. https://doi.org/10.1097/01.NUMA.0000651208.47176.91 .

Sepe P, Hargreaves J. Responding to the COVID-19 pandemic with the pathway to Excellence® framework. Nurs Manage. 2020;51:6–8. https://doi.org/10.1097/01.NUMA.0000688980.49993.c0 .

ANA, Find a Magnet. Organization. 2017. https://www.nursingworld.org/organizational-programs/magnet/find-a-magnet-organization/ . Accessed 20 Feb 2024.

ANA, Find a Pathway. Organization. 2017. https://www.nursingworld.org/organizational-programs/pathway/find-a-pathway-organization/ . Accessed 20 Feb 2024.

Schweiger J. Das Magnet-Krankenhaus — Anziehend durch Qualität und Transparenz. Pflegez. 2017;70:18–21. https://doi.org/10.1007/s41906-017-0090-4 .

Osterloh F. Zusammenarbeit Von Ärzten Und Pflegekräften: Der Kulturwandel hat begonnen. Deutsches Ärzteblatt. 2019;116:930–1.

Google Scholar  

Maier C, Köppen J, Kleine J. Das Arbeitsumfeld in Krankenhäusern verbessern - das Magnet4Europe-Projekt. Die Schwester Der Pfleger. 2022:84–7.

Kleine J, Maier CB, Köppen J, Busse R. Magnet®-Krankenhäuser: Eine Chance für Deutschland? In: Klauber J, Wasem J, Beivers A, Mostert C, editors. Schwerpunkt Personal. Berlin: Springer; 2023. pp. 107–17. https://doi.org/10.1007/978-3-662-66881-8_7 .

Chapter   Google Scholar  

Graystone R, Pabico C. Magnet® or Pathway® recognition: comparing and contrasting. J Nurs Adm. 2018;48:233–4. https://doi.org/10.1097/NNA.0000000000000606 .

Lal MM, Pabico CG. Magnet® and pathway: partners for nursing Excellence. J Nurs Adm. 2021;51:175–6. https://doi.org/10.1097/NNA.0000000000000992 .

Mororó DDS, Enders BC, Lira ALBC, Da Silva CMB, de Menezes RMP. Concept analysis of nursing care management in the hospital context. Acta Paul Enferm. 2017;30:323–32. https://doi.org/10.1590/1982-0194201700043 .

de Moura AA, Bernardes A, Balsanelli AP, Zanetti ACB, Gabriel CS. Liderança E satisfação no trabalho da enfermagem: revisão integrativa. Acta Paul Enferm. 2017;30:442–50. https://doi.org/10.1590/1982-0194201700055 .

Specchia ML, Cozzolino MR, Carini E, Di Pilla A, Galletti C, Ricciardi W, Damiani G. Leadership styles and nurses’ job satisfaction. Results of a systematic review. Int J Environ Res Public Health. 2021. https://doi.org/10.3390/ijerph18041552 .

Schaufeli W. Engaging Leadership: how to promote Work Engagement? Front Psychol. 2021;12:754556. https://doi.org/10.3389/fpsyg.2021.754556 .

Wang X, Chontawan R, Nantsupawat R. Transformational leadership: effect on the job satisfaction of registered nurses in a hospital in China. J Adv Nurs. 2012;68:444–51. https://doi.org/10.1111/j.1365-2648.2011.05762.x .

Cummings GG, Tate K, Lee S, Wong CA, Paananen T, Micaroni SPM, Chatterjee GE. Leadership styles and outcome patterns for the nursing workforce and work environment: a systematic review. Int J Nurs Stud. 2018;85:19–60. https://doi.org/10.1016/j.ijnurstu.2018.04.016 .

Moon SE, van Dam PJ, Kitsos A. Measuring transformational Leadership in establishing nursing Care Excellence. Healthc (Basel). 2019. https://doi.org/10.3390/healthcare7040132 .

Bass B, Avolio B. Improving Organisational Eectiveness through transformational Leadership. Thousand Oaks, CA, USA: Sage; 1994.

Avolio B. Full range leadership development. 2nd ed. Thousand Oaks, CA: SAGE; 2011.

Book   Google Scholar  

Burns JM. Leadership. New York. NY, USA: Harper & Row; 1978.

Bormann L, Abrahamson K. Do staff nurse perceptions of nurse leadership behaviors influence staff nurse job satisfaction? The case of a hospital applying for Magnet® designation. J Nurs Adm. 2014;44:219–25. https://doi.org/10.1097/nna.0000000000000053 .

Prado-Inzerillo M, Clavelle JT, Fitzpatrick JJ. Leadership practices and Engagement among Magnet® Hospital Chief nursing officers. J Nurs Adm. 2018;48:502–7. https://doi.org/10.1097/NNA.0000000000000658 .

Shaughnessy MK, Quinn Griffin MT, Bhattacharya A, Fitzpatrick JJ. Transformational Leadership practices and Work Engagement among Nurse leaders. J Nurs Adm. 2018;48:574–9. https://doi.org/10.1097/NNA.0000000000000682 .

Labrague LJ, Nwafor CE, Tsaras K. Influence of toxic and transformational leadership practices on nurses’ job satisfaction, job stress, absenteeism and turnover intention: a cross-sectional study. J Nurs Manag. 2020;28:1104–13. https://doi.org/10.1111/jonm.13053 .

Suliman M, Aljezawi M, Almansi S, Musa A, Alazam M. Ta’an WF. Identifying the nurse characteristics that affect anticipated turnover. Nurs Manag (Harrow). 2020. https://doi.org/10.7748/nm.2020.e1956 .

Ferreira VB, Amestoy SC, Da Silva GTR, Trindade LL, Santos IARD, Varanda PAG. Transformational leadership in nursing practice: challenges and strategies. Rev Bras Enferm. 2020;73:e20190364. https://doi.org/10.1590/0034-7167-2019-0364 .

Boyal A, Hewison A. Exploring senior nurses’ experiences of leading organizational change. Leadersh Health Serv (Bradf Engl). 2016;29:37–51. https://doi.org/10.1108/LHS-03-2015-0005 .

Salmela S, Eriksson K, Fagerström L. Leading change: a three-dimensional model of nurse leaders’ main tasks and roles during a change process. J Adv Nurs. 2012;68:423–33. https://doi.org/10.1111/j.1365-2648.2011.05802.x .

Kodama Y, Fukahori H. Nurse managers’ attributes to promote change in their wards: a qualitative study. Nurs Open. 2017;4:209–17. https://doi.org/10.1002/nop2.87 .

Kilian R. Transformationale Führung in der Pflege als Beitrag zur Managemententwicklung [Dissertation]. Private Universität für Gesundheitswissenschaften: Medizinische Informatik u. Technik Hall in Tirol (UMIT); 2013.

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349–57. https://doi.org/10.1093/intqhc/mzm042 .

Mayring P. Qualitative inhaltsanalyse: Grundlagen Und Techniken. 11th ed. Weinheim: Beltz; 2010.

Golafshani N. Understanding reliability and validity in qualitative research. TQR. 2015. https://doi.org/10.46743/2160-3715/2003.1870 .

Gavetti G. PERSPECTIVE—Toward a behavioral theory of strategy. Organ Sci. 2012;23:267–85. https://doi.org/10.1287/orsc.1110.0644 .

Gavetti G, Levinthal DA, Rivkin JW. Strategy making in novel and complex worlds: the power of analogy. Strat Mgmt J. 2005;26:691–712. https://doi.org/10.1002/smj.475 .

Moon B-J. Antecedents and outcomes of strategic thinking. J Bus Res. 2013;66:1698–708. https://doi.org/10.1016/j.jbusres.2012.11.006 .

Smriti V, Dhir S, Dhir S. Strategic thinking in Professional Environment: a review of the literature. IJBIR. 2020;1:1. https://doi.org/10.1504/IJBIR.2020.10028592 .

Masood M, Afsar B. Transformational leadership and innovative work behavior among nursing staff. Nurs Inq. 2017. https://doi.org/10.1111/nin.12188 .

Hamdani MR. Learning how to be a transformational leader through a skill-building, role-play exercise. Int J Manage Educ. 2018;16:26–36. https://doi.org/10.1016/j.ijme.2017.11.003 .

Cummings GG, Lee S, Tate K, Penconek T, Micaroni SPM, Paananen T, Chatterjee GE. The essentials of nursing leadership: a systematic review of factors and educational interventions influencing nursing leadership. Int J Nurs Stud. 2021;115:103842. https://doi.org/10.1016/j.ijnurstu.2020.103842 .

Cohrs C, Bormann KC, Diebig M, Millhoff C, Pachocki K, Rowold J. Transformational leadership and communication. LODJ. 2020;41:101–17. https://doi.org/10.1108/LODJ-02-2019-0097 .

Avolio BJ, Walumbwa FO, Weber TJ. Leadership: current theories, research, and future directions. Annu Rev Psychol. 2009;60:421–49. https://doi.org/10.1146/annurev.psych.60.110707.163621 .

Ahmed Mohamed Ibrahim S, Mohammed Araby Ebraheem S, Hassan EL-S, Mahfouz H. Effect of Educational Program about Head nurses’ Agile Leadership on Staff nurses’ Workplace spirituality and job reputation. Egypt J Health Care. 2022;13:1638–58. https://doi.org/10.21608/ejhc.2022.231783 .

Aij KH, Teunissen M. Lean leadership attributes: a systematic review of the literature. J Health Organ Manag. 2017;31:713–29. https://doi.org/10.1108/JHOM-12-2016-0245 .

Simonovich SD, Spurlark RS, Badowski D, Krawczyk S, Soco C, Ponder TN, et al. Examining effective communication in nursing practice during COVID-19: a large-scale qualitative study. Int Nurs Rev. 2021;68:512–23. https://doi.org/10.1111/inr.12690 .

Bailey KD, Losty LS, Albert D, Rodenhausen N, Santis JP. de. Leadership presence: A concept analysis. Nurs Forum. 2022;57:1069–79. https://doi.org/10.1111/nuf.12784 .

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Acknowledgements

We extend our thanks to the 18 interviewees for their time and valuable insights, especially considering the challenges posed by the COVID-19 pandemic during the interview data collection period. Their willingness to participate in this study is greatly appreciated and has significantly contributed to our research. We also thank the consortium of the Magnet4Europe study.

The Magnet pioneer study was funded by the B. Braun Foundation (Grant No. 18001021). Additional time on the study was funded by a grant from Robert Bosch Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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CBM was the PI of the Magnet pioneer study and planned the study and its methodology. CBM and JuK contributed to the study’s design. CBM, JuK and JoK performed data collection and conducted the deductive analysis of the data. JoK conducted the main inductive analyses for the purpose of the current study. CBM and JuK provided critical review and discussion of inductive coding. JoK wrote the first draft manuscript, and prepared tables. CBM, JuK and CG were involved in subsequent iterations and conducted critical review of the manuscript.

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This research has been performed in accordance with the Declaration of Helsinki with ethics approval through the Ethics Committee of the Charité (No. EA4/185/19). Written informed consent was obtained from all interviewees prior to the interviews. For interviewees, neither advantages nor disadvantages resulted from participation or non-participation in the study. Participation could be withdrawn at any time without consequences till anonymizations.

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Kleine, J., Köppen, J., Gurisch, C. et al. Transformational nurse leadership attributes in German hospitals pursuing organization-wide change via Magnet® or Pathway® principles: results from a qualitative study. BMC Health Serv Res 24 , 440 (2024). https://doi.org/10.1186/s12913-024-10862-y

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• 1 Reprinted from Robbins B, Davidhizar R. Transformational leadership in health care today. Health Care Manag. 2007;26(3):234-239. doi:10.1097/01.HCM.0000285014.26397.e7. Author Affiliations: Lakeland Regional Health System, Saint Joseph, Michigan (Ms Robbins) and School of Nursing, Bethel College, Mishawaka, Indiana (Dr Davidhizar).
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Management in nursing is in a state of revolution based on positive transformational changes. Effective leadership on individual nursing units directly affects nursing staff satisfaction. Employees are interested in managers who can lead in a positive and encouraging manner. Nurses who are content in their positions correlate to a reduction in staff turnover and improve retention. When the nursing staff are satisfied with their employment, patient satisfaction rises. Health care organizations can see this trickle-down effect through increases in patient satisfaction scores over time. The promotion of effective communication and positive attitudes enhances a healthy environment for all employees and staff. Health care organizations should evaluate individual nurse managers on units to promote transformational leadership qualities; this will directly result in staff satisfaction, staff retention, and patient satisfaction.

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The Path Is the Goal: How Transformational Leaders Enhance Followers’ Job Attitudes and Proactive Behavior

While leading through goals is usually associated with a task-oriented leadership style, the present work links goal setting to transformational leadership. An online survey with two time points was conducted with employees to investigate the influence of transformational leadership on followers’ job satisfaction, organizational commitment, and proactive behavior via goal attributes. Findings indicate that transformational leaders influence the extent to which followers evaluate organizational goals as important and perceive them as attainable. Multiple mediation analysis revealed that these goal attributes transmit the effect of transformational leadership on followers’ job attitudes and proactive behavior. However, goal importance and goal attainability seem to be of differential importance for the different outcomes.

Introduction

Although the setting of goals has been emphasized to be one of the most important tasks of leaders (e.g., Tett et al., 2000 ), goals and leadership have commonly been considered from two relatively independent research perspectives (cf. Berson et al., 2015 ). In the field of goal research many efforts centered on the setting of goals in organizational contexts. As a core finding, a multitude of studies (for an overview: Locke and Latham, 2002 ) revealed that setting specific and moderately difficult goals results in increases of an individual’s performance as such goals direct one’s attention, induce greater effort, enhance one’s persistence, and elicit the use of task-related knowledge and strategies ( Locke and Latham, 2002 ). Studies further showed that the strength of this association depends on certain goal attributes, an individual’s self-efficacy beliefs, as well as feedback on and the complexity of the task. Apart from its impact on an individual’s job performance and work motivation, goal setting is also an important determinant of one’s self-regulation ( Latham and Locke, 1991 ). Their self-regulative function results as specific and difficult goals point out a discrepancy between a current and a future state and clarify the acceptable level of performance ( Latham and Locke, 1991 ). Goals, however, may not only be set by another person but also by an individual him-/herself. Personal goals and their pursuit have been another line of interest for goal researchers (e.g., Emmons, 1986 ; Brunstein, 1993 ). In the field of leadership research, goals have initially been assigned a dominant role in those conceptions, which highlight a leader’s task orientation. Task-oriented leaders focus on getting their work done and completing assignments ( Bass, 1990 ). Such leaders therefore emphasize goals, foster their achievement, and monitor followers’ goal pursuit. In this regard, goals may be seen as a means to exert control in leader-follower interactions.

Instead of viewing the assignment of goals as a way to monitor followers, in the present study, we embed the goal setting of leaders into the context of motivating and enabling subordinates. In so doing, we concentrate on the construct of transformational leadership, as transformational leaders (TLs) not only have high performance expectations ( Bass, 1985 ), but rather inspire and empower their subordinates ( Bass and Riggio, 2006 ). In motivating and enabling followers, goals have variously been assigned a central role in the theory of transformational leadership (e.g., Shamir et al., 1993 ; Conger and Kanungo, 1998 ). Therefore, a goal-perspective to transformational leadership is straightforward.

Given that setting goals is a common leadership task ( Tett et al., 2000 ), it is indispensable to incorporate well-founded knowledge accumulated in the field of goal research into study efforts on effective leadership. Only if we consider both research domains jointly, we can get the best picture possible of how leaders influence followers and the way they pursue the goals these leaders set. Intertwining findings and theoretical assumptions on goal setting, self-regulative goal pursuit, and personal goals with empirical evidence and theorizing on transformational leadership, we assume TLs to foster followers’ perception of organizational goals to be important and attainable, and by these means, to increase their job satisfaction, organizational commitment, and proactive behavior. That way, the present study helps in bringing together the different streams of research and to generalize extant evidence on assigned and personal goals to the goal setting within leader-follower-interactions. In so doing, our study investigates fundamental assumptions on the inner workings of transformational leadership for which empirical evidence is yet scarce. As such, the present work also contributes to further substantiating theoretically derived mechanisms of transformational leadership and thus to our understanding of how these leaders exert their extraordinary influence on followers.

Motivating and Enabling Employees: The Transformational Leadership Approach

TLs motivate followers to commit themselves to organizational objectives and to realize performance outcomes, which exceed beyond expectations. According to Bass (1985) , leaders accomplish this process of motivating and transforming followers by (1) heightening their awareness of the importance and value of designated goals, (2) encouraging them to transcend self-interests for the good of the organization or team, and (3) activating their higher order needs as TLs articulate an inspiring vision and act as role models in attaining the vision. More specifically, TLs are able to ideally influence subordinates due to their exceptional charisma and prompt followers to personally identify with them ( Bass, 1985 ). Based on this emotional attachment, TLs instill within followers the desire to emulate their leaders and thus become followers’ role models. TLs envision an appealing future goal state for their team or the entire organization and express confidence in followers’ abilities to attain this higher-order goal ( Bass, 1985 ). By this means, they inspirationally motivate followers to achieve more than expected. As they tie the ideological vision to the collective’s future, TLs foster the acceptance of group goals and enhance the cooperation within teams ( Podsakoff et al., 1990 ). Besides, they intellectually stimulate followers to question their way of working and to take on new perspectives increasing subordinates’ awareness of problems that way ( Podsakoff et al., 1990 ). TLs clearly express the high performance demands they have and expect excellence and high quality work from followers ( Podsakoff et al., 1990 ). Concurrently, they also attend to followers’ needs, listen to their particular concerns, and are individually considerate toward them ( Bass, 1985 ).

After the key behaviors used to transform and motivate followers had been identified, Conger and Kanungo (1998) claimed that more insights into the process of motivating and transforming followers were needed and called for a more processual perspective on transformational leadership. They developed a three-stage model, which aimed at illustrating how TLs transform subordinates and move them from an existing present state toward some future state. According to this model, TLs first examine the current situation at work and its surrounding environment. In this initial stage, they actively search the status quo for existing or potential shortcomings. Based on the deficiencies they identify, goals are then derived, formulated, and conveyed in the second stage. By articulating a very discrepant and idealized goal, TLs provide a sense of challenge and a motivating force for change to their followers ( Conger, 1999 ). In the final stage, they build trust in the goals they disseminate and demonstrate how these goals can be attained. The model thus highlights the communication and implementation of a vision or goal as a key mechanism of transformational leadership.

Goal Setting, Self-Regulation, and Personal Goals

In the work context, goals may help to predict, explicate, and affect an employee’s job performance ( Locke and Latham, 2002 ). By setting followers’ goals, leaders create a discrepancy between a current situation and a future state and, with regard to work-related tasks, emphasize what constitutes an adequate level of performance. That way, they provide a sense of purpose, which coordinates and guides their followers’ action ( Latham and Locke, 1991 ).

After a goal is communicated or set, leaders often do not have direct control over their subordinates’ goal pursuit anymore and followers have to plan and organize the goal striving process autonomously. In order to attain organizational goals, employees therefore have to be able to self-regulate at work. Traditionally, self-regulation is defined as processes that “enable an individual to guide his/her goal-directed activities over time and across changing circumstances (contexts), [… including the] modulation of thought, affect, behavior, or attention” ( Karoly, 1993 , p. 25). This definition points out that in the process of self-regulation, goals are an essential component ( Vancouver, 2000 ). Moreover, it describes self-regulation as a volitional process of translating the goals, which have been set into action. In a series of experiments, Oettingen et al. (2001) identified three self-regulatory thought processes, which are of relevance within an autonomous goal setting process: mentally contrasting the desired future with reality, dwelling on negative aspects of the current reality, and indulging in the desired future. The authors observed that as a function of these three self-regulatory thoughts, feelings of identification with the goal, expectations of success, and effortful goal striving result.

Self-regulated goal striving is also addressed in the field of personal goal research. Personal goals are set by an individual him-/herself and are therefore person-specific. Models of personal goal pursuit emphasize the personal significance and uniqueness of these goals and acknowledge the autonomy and self-determination during the goal striving process (e.g., Emmons, 1986 ; Brunstein, 1993 ). Knowledge gathered in the domain of personal goals may give valuable insights into the way TLs facilitate their followers’ goal pursuit. As TLs intertwine the goals they set with followers’ self-concepts ( Shamir et al., 1993 ) and lead them to internalize these goals ( Bono and Judge, 2003 ), subordinates perceive these goals to be highly self-consistent ( Shamir et al., 1993 ) and feel goal-directed actions to be driven by personally held values ( Bono and Judge, 2003 ). TLs hence seem to be able to turn organizational goals into followers’ personal goals. According to the personal goal model of well-being (for an overview: Brunstein et al., 1999 ), which is well-established in the field of personal goal research, there are two decisive factors that determine one’s success in pursuing personal goals as well as the subjective well-being of the goal striver: the valence followers attach to the goals and the degree to which they perceive the goals to be attainable. Whereas a goal’s importance increases one’s determination in pursuing the goals ( Maier and Brunstein, 2001 ), the evaluation of a goal to be attainable first leads individuals to decide to pursue that goal ( Heckhausen and Kuhl, 1985 ). Maier and Brunstein (2001) adapted this model to the work domain and report evidence, which suggests that the two goal attributes account for changes in job satisfaction and organizational commitment. They conclude that “to achieve well-being and avoid distress, it is important for individuals to have both a strong sense of commitment to valued goals and a life situation that provides favorable conditions to materialize these goals” ( Maier and Brunstein, 2001 , p. 1035).

Combining self-regulation theory and the personal goal model, one can assume that the goal attributes highlighted in the personal goal model result from the self-regulatory processes Oettingen et al. (2001) found to be related to an autonomous goal striving. Goal importance and goal attainability may thus be considered indicators of an autonomous goal pursuit regardless of whether the goal had been set by a leader or by the follower him-/herself. If we transfer these considerations to the organizational goal setting process, we assume that in order to facilitate followers’ goal pursuit, leaders have to enhance their followers’ evaluation of the goal’s importance and attainability.

Transformational Leaders as Facilitators of the Goal Pursuit of Employees

Although theoretically the effectiveness of transformational leadership has widely been ascribed to its impact on followers’ perception of organizational goals, empirically this relation experienced far less attention. Those studies which indeed focused on goal attributes found transformational leadership to positively relate to followers’ evaluation of the goal’s specificity and difficulty ( Whittington et al., 2004 ; Bronkhorst et al., 2015 ), as well as its clarity ( Wright et al., 2012 ). Followers of TLs further rated organizational goals to be more consistent with their own values and interests ( Bono and Judge, 2003 ) and showed a higher agreement with their leaders on strategic goals ( Berson and Avolio, 2004 ). On the team level, transformational leadership was associated with higher levels of team goal commitment ( Chi et al., 2011 ) and a higher congruence with regard to the importance team members attach to the goals ( Colbert et al., 2008 ).

In line with our reasoning on the value of a goal’s importance and attainability in an autonomous goal accomplishment, Latham and Locke (1991) stated that leaders can play a significant role in facilitating their followers’ goal pursuit by convincing them that the goals are both important and attainable. In the present study, we therefore concentrate on these goal attributes and their relation to transformational leadership.

Empirically, transformational leadership has already been related to a goal’s importance ( Colbert et al., 2008 ). This study, though, focused on the degree of goal importance congruence among team members. Finer-grained analyses, however, suggested that rather than the degree of congruence it is an individual’s goal importance perception as such which positively relates to transformational leadership and followers’ job-related attitudes. To substantiate these initial findings and hence theoretical assumptions on the mechanisms of transformational leadership, followers’ individual evaluations of a goal’s importance have to be further examined in the context of these leadership behaviors. Goal clarity, specificity, or difficulty have also been studied with regard to transformational leadership ( Wright et al., 2012 ; Bronkhorst et al., 2015 ). Besides, this leadership style has been shown to be closely associated with followers’ broader feeling of having the ability to perform successfully ( Kark et al., 2003 ). However, irrespective of the central role it has been assigned theoretically, evidence on the impact of transformational leadership on followers’ perception of a specific goal’s attainability is yet missing. Studies linking transformational leadership and followers’ perception of a goal’s importance and attainability may thus give further evidence-based insides into the process of how TLs transform followers and motivate them to achieve more than expected beyond existing research.

Transformational Leadership and Goal Importance

Goal importance refers to the significance an individual assigns to a certain goal and its achievement relative to other work- or non-work-related goals ( Hollenbeck and Williams, 1987 ). It indicates how closely one regulates this goal compared to other goals ( Powers, 1978 ). Goal importance is a significant driver of an individual’s goal commitment ( Locke and Latham, 2002 ), and, as such, aligns one’s feelings and actions to the accomplishment of the specific goal ( Hollenbeck and Klein, 1987 ). As a result, people extend their effort and invest more time even if they face difficulties or obstacles during the goal pursuit. In sum, goal importance is a significant determinant of one’s motivation to achieve certain goals ( Bandura, 1997 ). For this reason, it is of major interest to figure out leadership techniques, which help to increase followers’ perception of an organizational goal’s importance.

In the very beginning, researchers argued that supervisors’ legitimate authority to assign goals or their physical presence was sufficient to create commitment to and raise a goal’s importance ( Ronan et al., 1973 ). Later, Latham and Saari (1979) showed that a supportive leadership style increased the importance attached to goals and that providing a rationale for the goal also functioned as a facilitator (“tell and sell” style; Locke et al., 1988 ). Moreover, if leaders communicate an inspiring vision they may enhance the attractiveness of attaining a certain goal and accentuate its importance ( Berson and Avolio, 2004 ). Vision articulation, rationales, and a supportive leadership style seem to foster followers’ goal acceptance by making them more likely to see the consequences of goal attainment as rewarding or favorable ( Locke and Latham, 2002 ). In addition, goals gain in importance if followers are involved in the goal setting process. Under this condition, they own the goals agreed upon ( Locke and Latham, 2002 ). Sheldon et al. (2002) developed a goal intervention program, which aimed at increasing one’s sense of ownership. They asked participants to reflect upon the meaningfulness of goals and to consider the core values these goals express (“Own the goal” strategy). Besides, participants were motivated to reflect upon the longer-term goals their current goals serve (“Remember the big picture” strategy). These strategies as well as the leadership attributes, which have been found to strengthen followers’ perception of a goal’s importance, closely match the behaviors TLs use in leading. TLs articulate an ideological vision of an attractive future goal state and frame the work in terms of collectively approved values ( Shamir et al., 1993 ). That way, they provide a meaningful and stimulating rationale for the work to be done but also transform followers’ beliefs and values ( Conger and Kanungo, 1998 ). By aligning followers’ values to the higher-order mission they articulate, TLs create a purpose in work that exceeds beyond extrinsic outcomes ( Arnold et al., 2007 ) and increase the meaningfulness of goal accomplishment ( Shamir et al., 1993 ). Besides strengthening the importance of organizational goals via their alignment to an ideological vision, TLs also foster followers’ sense of ownership by involving them in important organizational decisions. In so doing, TLs delegate responsibilities, are open to followers’ ideas and reasoning, and consider their needs in leading ( Avolio et al., 1991 ).

As TLs present work and especially organizational goals in terms of a higher-order vision and link them to subordinates’ values but also grant subordinates responsibility during the goal pursuit, we assume followers to perceive the goals their TLs set to be more important.

Hypothesis 1: We suggest that the more transformational followers perceive their supervisors to lead, the higher the importance they attach to the organizational goals set by or agreed upon with these leaders.

Transformational Leadership and Goal Attainability

Goal setting theory states that for goals to be motivational, they have to be specific and challenging but yet attainable ( Locke and Latham, 1990 , 2002 ). Goal attainability indicates how favorable or unfavorable goal strivers perceive external conditions with respect to their goal progress. If an individual perceives a goal to be attainable, he/she has various opportunities to strive toward the goal, has control over the goal striving process, and receives goal-related support from his/her social network ( Brunstein, 1993 ). Accordingly, leaders have three levers to adjust in order to make goals more attainable: opportunities, control, and support.

Social support is an important resource in facilitating employees’ work and enhancing their work attitudes (e.g., Hochwarter et al., 1999 ; Viswesvaran et al., 1999 ). In a meta-analysis, Ng and Sorensen (2008) showed that compared to colleagues or the organization as a whole, supervisors are the most valuable source of social support. This value of supervisory support is also acknowledged by the theory of transformational leadership. One of its key components, individualized consideration, includes behaviors such as encouraging followers, acting as their coaches or mentors, and being caring and nurturing ( Bass and Avolio, 1994 ; Conger and Kanungo, 1998 ). Besides, TLs demonstrate how goals may be attained ( Conger, 1999 ). By providing this kind of social and instrumental support, TLs are likely to positively affect followers’ perception of being able to attain the goals set by their leaders. TLs foster each follower’s personal and professional development ( Bass and Avolio, 1994 ) and promote their growth, independence, and empowerment ( Bass, 1985 ; Kark et al., 2003 ). To achieve these ends, they use empowering leadership behaviors such as delegating responsibilities and enabling employees to make important decisions, providing resources, and background information about organizational processes, as well as enhancing followers’ capacity to think and question familiar ways of working ultimately raising followers’ self-efficacy beliefs that way ( Avolio et al., 1991 ; Menon, 2001 ; Dvir et al., 2002 ; Kark et al., 2003 ). Self-effective and empowered persons believe in their capability to perform successfully, have a sense of having choice in initiating and regulating actions, and are able to influence outcomes at work ( Spreitzer, 1995 ). As such, these followers ought to feel a higher degree of control with regard to their goal striving. Along with the autonomy they grant, the resources they provide, and the error culture they propagate, the intellectual stimulation TLs practice leads followers to also see and explore new ways of approaching their jobs and completing their tasks ( Peng et al., 2016 ). This motivation to rethink the way they pursue organizational goals likely makes followers aware of new and different opportunities they have in striving toward these goals.

Transformational leaders are hence able to positively impact all three levers leaders may adjust in order to increase followers’ perception of being able to attain their organization’s goals. Therefore, we assume a positive association between transformational leadership and followers’ attainability evaluation of the goals, which had been set by or agreed upon with these leaders.

Hypothesis 2: We suggest that the more transformational followers perceive their supervisors to lead, the higher the attainability they ascribe to the organizational goals set by or agreed upon with these leaders.

Transformational Leadership, Goal Attributes, and Followers’ Job Attitudes and Performance

We were not only interested in the question whether TLs are able to facilitate their followers’ goal pursuit but also in showing that this process of motivating and enabling makes a particular contribution to an organization’s functioning. An extant body of meta-analytic evidence shows that TLs substantially influence their subordinates’ job attitudes, motivation, performance, and proactive behavior at work ( Fuller et al., 1996 ; Lowe et al., 1996 ; Judge and Piccolo, 2004 ; Wang et al., 2011 ). Out of the multitude of possible outcomes, we drew on indicators of successful organizational adaptation, as today’s changing work environments and competitive market situation require organizations to easily and quickly adapt to new challenges ( Gordon and Yukl, 2004 ). Specifically, we examined followers’ job satisfaction, organizational commitment, and proactive behavior for indicating an employee’s willingness to accept new challenges in the future ( Bateman and Crant, 1993 ; Cordery et al., 1993 ; Yousef, 2000 ).

Previous research also confirmed a clear link between the two goal attributes importance and attainability and followers’ affective job attitudes as well as their performance (e.g., Lee et al., 1991 ; Maier and Brunstein, 2001 ; Locke and Latham, 2002 ). In line with these findings, we assume that TLs facilitate their followers’ goal pursuit process and exert their positive influence on work attitudes and proactive behavior by increasing followers’ perception of the importance and attainability of organizational goals.

Hypothesis 3: We suggest that followers’ evaluations of the organizational goal attributes importance and attainability jointly mediate the relationship between their perception of their leaders’ transformational leadership behavior and (a) their job satisfaction, (b) organizational commitment, and (c) proactive behavior.

Materials and Methods

Procedures and participants.

In order to test our hypotheses, we collected data via an online questionnaire at two measurement occasions. At T1, participants were asked to evaluate their leader’s leadership behavior and to list three organizational goals. For each of these goals, participants then indicated its importance and attainability. Job satisfaction, organizational commitment, and proactive behavior were assessed at the second measurement occasion, which was scheduled 4 weeks after the first measures had been taken. We chose this time lag since influences of leadership behavior on employees’ well-being are more likely to be detected within a short than within a long period of time ( van Dierendonck et al., 2004 ). Data sets were matched based on a pre-structured ten-digit code, which participants generated at T1 and T2.

At the beginning and at the end of the first part of the survey, we informed participants that the study consisted of two parts. After completing T1, participants indicated whether they agreed to also respond to the second questionnaire. Those who were inclined to do so were further requested to provide an email address to which the link to the second part was sent by the survey software. In order to ensure anonymity, the survey software had been programmed in a way so that it automatically sent without our assistance a prewritten invitation mail to the second part of the survey to the address participants stated at T1. In the instruction, this procedure was explained in detail. Before we matched the data across measurement occasions and started to analyze them, email addresses were removed from the data set.

Prior to collecting the data, we presented the study to our university’s ethics committee. As it did not deviate from legal regulations or the ethical guidelines of the German Association of Psychology, the ethics committee authorized the study in its final form. Due to the online assessment, we did not personally interact with participants and therefore did not obtain their signed declarations of consent. Yet, we informed them about the study’s content, duration, and aims, and we highlighted that, at any time, participants could abandon the online questionnaire by closing the browser or tab. Participants were assured that incomplete data sets would be deleted and would not be incorporated into our analyses. Moreover, quoting their individual ten-digit code they had developed during the survey, participants were granted the opportunity to still withdraw their data after completing the entire questionnaire.

Participants were recruited in (virtual) business networks and on social media platforms. In sum, 292 employees finished the first part of the questionnaire, but only 144 of them completed its second part. Given the high drop-out rate (50.68%), we compared the responses of those finishing the entire survey with those of participants who did not answer its second part. Analyses did not reveal any systematic drop-out (all p > 0.05). Due to missing data across both measurement occasions, we had to exclude 16 participants from the analyses, so that the final sample consisted of 128 followers. Among them, 60.90% were females. The average age was 36.17 years ( SD = 11.50 years). Participants were employed in a variety of industries (i.e., service companies, retail stores, public services, industrial companies) and had been working for their current organization an average of 8–9 years ( M = 8.57, SD = 8.99). At the time they completed the survey, followers had been collaborating with their current leader for about three and a half years ( M = 3.52, SD = 3.36).

Listing and Assessment of Organizational Goals

In accordance with prior research (e.g., Maier and Brunstein, 2001 ), we ideographically assessed organizational goals by asking participants to freely generate and notice up to three work-related goals. Goals were defined as objectives, projects, and plans related to one’s job that were set by or agreed upon with one’s leader. Given the future-orientation of the higher-order vision transformational leaders articulate ( Bass, 1985 ), participants were instructed to focus on those goals they were encouraged to pursue during the following 12 months. After listing these goals, participants indicated the extent to which they perceived each of them to be important and attainable on a five-point response scale ranging from 1 = not at all to 5 = very much . We computed an overall measure of goal importance and goal attainability by averaging responses across the three goals. A major precondition for aggregating within-person data to the between-person level is sufficient reliability of the aggregate. In order to determine the homogeneity [ICC(1)] and reliability [ICC(2)] of the goal ratings, we calculated intraclass correlation coefficients as suggested by Lüdtke and Trautwein (2007) . ICC(1) coefficients were 0.38 for importance and 0.37 for attainability. The corresponding ICC(2) coefficients were 0.65 and 0.64, respectively. ICC(2) is a function of ICC(1) and the number of goals assessed and reliability increases the more goals that are being evaluated. As in the present study only three goals were assessed, intraclass correlation coefficients are within an acceptable range ( Lüdtke and Trautwein, 2007 ).

Transformational Leadership

To determine followers’ perceptions of their leaders’ transformational leadership behavior, we used the Transformational Leadership Inventory by Podsakoff et al. (1990) ; German form: Heinitz and Rowold (2007) . With its 22 items, the scale covers the transformational leadership behaviors articulating a vision (“My supervisor paints an interesting picture of the future for our group”), providing an appropriate model (“My supervisor provides a good model for me to follow”), fostering the acceptance of group goals (“My supervisor gets the group to work together for the same goal”), articulating high performance expectations (“My supervisor shows us that he/she expects a lot from us”), providing individualized support (“My supervisor behaves in a manner thoughtful of my personal needs”), and offering intellectual stimulation (“My supervisor challenges me to think about old problems in new ways”). On a response scale ranging from 1 = never to 5 = almost always followers stated how often their leaders use the behaviors illustrated. The internal consistency of the measure was α = 0.93.

Job Satisfaction

Participants’ job satisfaction was measured using the short version of Neuberger and Allerbeck’s (1978) Job Description Form. The unidimensional scale covers one’s satisfaction with seven facets of work (working conditions, tasks, relationship with colleagues, relationship with the supervisor, promotion opportunities, organization and management, and salary). Items were rated on a seven-point Kunin-scale ranging from 1 = completely dissatisfied to 7 = completely satisfied . Reliability of the scale was 0.82.

Organizational Commitment

Organizational commitment was measured with the short version of the Organizational Commitment Questionnaire ( Mowday et al., 1979 ; German form: Maier and Woschée, 2002 ). Participants were asked to indicate their agreement (ranging from 1 = strongly disagree to 5 = strongly agree ) to nine statements about their identification with and involvement in their organizations (“For me this is the best of all possible organizations for which to work”). Cronbach’s alpha of the scale was 0.91.

Proactive Behavior

To assess participants’ proactive behavior, we used the respective subscale of an organizational citizenship behavior questionnaire ( Staufenbiel and Hartz, 2000 ). The scale comprises five items (“I bring in innovative ideas to improve the quality of my department”) which assess an employee’s voluntary behaviors directed at keeping oneself informed about one’s organization, advancing its quality and performance, as well as improving one’s own qualifications. Items were to be answered on a scale ranging from 1 = strongly disagree to 5 = strongly agree and showed an internal consistency of 0.82.

Table ​ Table1 1 presents the means, standard deviations, and correlations of the study variables. Hypotheses 1 and 2 assumed a positive association between transformational leadership and followers’ evaluation of the organizational goals that were set by or agreed upon with their leaders. As Table ​ Table1 1 shows, followers’ perception of their leaders’ transformational leadership behavior was indeed positively related to the importance they attach to these goals ( r = 0.30, p < 0.01) and to the attainability they ascribe to them ( r = 0.23, p < 0.01). Hypotheses 1 and 2 are thus supported.

Descriptive statistics and correlations of the study variables.

Hypothesis 3 supposed the goal attributes to jointly transmit the effect of transformational leadership on followers’ (a) job satisfaction, (b) organizational commitment, and (c) proactive behavior. To explore this assumption, we tested a multiple mediation model according to Preacher and Hayes (2008) using Hayes’ (2013) PROCESS macro for SPSS. Their approach allows the testing of multiple mediators and multiple outcomes also in smaller samples and accounts for the fact that the sampling distribution of total and indirect effects is commonly not normally distributed ( MacKinnon et al., 2004 ). In order to yield more precise estimates, total and specific indirect effects are bootstrapped and confidence limits for these effects are estimated. In our study, we drew on 95% bias-corrected and accelerated confidence intervals (BCa CI) based on 5,000 bootstrap samples. To test our hypothesis we modeled all variables (transformational leadership as predictor, goal importance and goal attainability as mediators operating in parallel, as well as job satisfaction, organizational commitment, and proactive behavior as outcomes) within a single multiple mediation model. In line with previous meta-analyses ( Fuller et al., 1996 ; Lowe et al., 1996 ; Judge and Piccolo, 2004 ; Wang et al., 2011 ), we found significant total effects of follower-rated transformational leadership on their job satisfaction ( b = 1.065, BCa CI [0.855, 1.275]), organizational commitment ( b = 0.671, BCa CI [0.488, 0.853]), and proactive behavior ( b = 0.282, BCa CI [0.084, 0.480]). For each outcome this effect decreased in size when the goal attributes were considered simultaneously (see the values of the direct effects of transformational leadership on the outcome variables displayed in Figure ​ Figure1 1 ). Whereas the direct effect of transformational leadership on job satisfaction and organizational commitment remained significant when controlling for goal attributes suggesting partial mediation, the one on proactive behavior turned out to be only marginally significant under this condition ( Figure ​ Figure1 1 ). Estimates of the total indirect effect show that, together, both goal attributes mediate the effect of perceived transformational leadership on followers’ job satisfaction ( b = 0.111, BCa CI [0.028, 0.241]), organizational commitment ( b = 0.071, BCa CI [0.014, 0.169]), and proactive behavior ( b = 0.086, BCa CI [0.020, 0.188]). Hypothesis 3 is thus supported. Given that we considered multiple mediators, we could not draw on Preacher and Kelley’s (2011) κ 2 in determining the size of the indirect effect, but had to rely on the ratio of the indirect effect to the total effect ( MacKinnon et al., 1995 ). One of the disadvantages of this effect size measure is that it may exceed 1 if the indirect effect is bigger than the total effect and may exhibit values below 0 if one of these effects is negative ( Hayes, 2013 ). For job satisfaction, 10.4% of the total effect of transformational leadership was transmitted by the goal attributes, for organizational commitment 10.5% of the total effect resulted from mediation, and in proactive behavior this proportion amounted to 30.4%.

Direct effects of transformational leadership on goal attributes and outcomes as well as of goal attributes on outcomes within the multiple mediation model.

Besides the total indirect effect, PROCESS also estimates the extent to which each mediator transmits the effect of the predictor on the outcome conditional on the presence of the other intervening variables operating in parallel ( Preacher and Hayes, 2008 ). These specific indirect effects give evidence on the relative magnitude of each mediator included in the model. As indicated by the confidence intervals displayed in Table ​ Table2, 2 , the effect of perceived transformational leadership on job satisfaction and proactive behavior was solely transmitted by followers’ evaluation of the goals’ attainability. With regard to their organizational commitment, we found the effect to be solely mediated by followers’ ratings of the goals’ importance. For this indirect effect, the confidence interval did not include zero. Goal attributes thus seem to be differentially important for the different outcomes.

Specific indirect effects of transformational leadership on job satisfaction, organizational commitment, and proactive behavior transmitted through the goal attributes goal importance and goal attainability.

The purpose of the present study was to examine the linkage between transformational leadership and followers’ job attitudes as well as their proactive behavior focusing on the goal setting process. We aimed at illustrating that TLs enable followers to autonomously organize their goal pursuit, which we assumed to find expression in higher follower perceptions of the importance and attainability of the goals these leaders set. In line with our assumptions, we indeed found positive relations between follower-rated transformational leadership and their assessment of both goal attributes. TLs articulate an ideological vision and lay emphasis on the meaning of tasks, but also grant followers responsibility and support. Together, these behaviors result in higher levels of identification with and commitment to the organizational goals these leaders set. By demonstrating confidence in their followers’ capability, increasing opportunities for them to significantly affect their work, and providing instrumental and emotional support, TLs lead employees to further perceive these goals to be attainable. Enhancing the importance and attainability of the goals they disseminate, TLs are thus able to facilitate their followers’ organizational goal striving.

In support of our third hypothesis, ratings of the goal attributes mediated the relation between followers’ perceptions of transformational leadership and their job satisfaction, organizational commitment, and proactive behavior. This result supplements earlier findings by Maier and Brunstein (2001) in the domain of personal goals based on which the authors concluded that a sense of commitment to valued goals and the perception of favorable conditions for goal attainment are important requirements for one’s well-being. Our findings suggest that this conclusion also holds when goals are set by a leader instead of followers themselves. Also during the pursuit of assigned goals at work, a goal’s importance and attainability are crucial for success and ultimately for one’s job-related well-being and performance.

Analyses of the specific indirect effects corroborate that goal importance and goal attainability differentially mediated the effect of transformational leadership on the outcomes considered. Whereas transformational leadership and job satisfaction as well as proactive behavior were solely associated via the perception of a goal’s attainability, these leadership behaviors unfolded their impact on followers’ organizational commitment via followers’ perceptions of the goal’s importance only. Concerning followers’ organizational commitment, we think that this mediation can be explained by a spread-out effect in which the appreciation of and identification with a certain vision or goal serves as a proxy for the whole organization. As Mowday et al. (1982) stated, organizational commitment is characterized by “a strong belief in and acceptance of the organization’s goals and values” (p. 27). Therefore, perceiving organizational goals as important is a relevant mechanism in transmitting the effect of transformational leadership on followers’ organizational commitment. Our finding that goal attainability does not significantly mediate this relation might be explained by the fact that employees expect their leaders to facilitate their work in any case ( Ng and Sorensen, 2008 ). Meta-analytic evidence, though, shows followers’ affective commitment to be most affected by perceptions of organizational support ( Meyer et al., 2002 ). As favorable conditions for goal attainment seem to be taken for granted ( Ng and Sorensen, 2008 ) and are thus not perceived as particular support, they probably do not specifically increase followers’ attachment to the organization. With regard to followers’ job satisfaction and proactive behavior, by contrast, goal attainability appeared to be a significant mediator conditional on the presence of goal importance as a second mediator. With regard to one’s satisfaction, this finding is in line with research on personal goals: In this domain, goal attainability has been meta-analytically shown to be associated with an individual’s subjective well-being (e.g., life satisfaction or positive affect); and personal work-related goals were found to more specifically relate to one’s job satisfaction ( Klug and Maier, 2015 ). Unfortunately, the association with a goal’s importance has not been considered within this integrative work. Our findings suggest that in order to be satisfied with one’s job, followers have to be convinced to be able to attain the organizational goals they have been assigned rather than considering these goals to be important. This finding deviates from evidence on the significance of one’s goal commitment within the goal setting theory (for an overview: Locke and Latham, 2002 ), as well as from evidence on the personal goal model of well-being corroborating that goals need to be both important and attainable in order to increase employees’ job satisfaction ( Maier and Brunstein, 2001 ). In addition, meta-analytic evidence in the field of work design highlights a task’s significance, which is closely associated with an organizational goal’s importance, to be a major correlate of one’s satisfaction with work ( Humphrey et al., 2007 ). As, based on this former research, we would have expected goal importance perceptions to equally mediate the effect of transformational leadership on followers’ job satisfaction, we recommend to reinvestigate the value of followers’ goal importance evaluations in relation to transformational leadership and subordinates satisfaction with work. Also with regard to followers’ proactive behavior, only attainability perceptions mediated the effect of transformational leadership. If employees believe they may affect work outcomes, their willingness to take responsibilities and action is stimulated ( Stajkovic and Luthans, 1998 ). Accordingly, followers who perceive favorable conditions for goal realization are likely to proactively develop these goals and ways to achieve the vision TLs articulate. In previous research, feelings of being able to successfully perform a task have rather been found to moderate the relation between transformational leadership and proactive behavior instead of mediating it ( Den Hartog and Belschak, 2012 ). This earlier work, though, assessed followers’ self-efficacy beliefs, whereas our study focused on the attributes of the goal. Whether TLs exert an identifiable independent influence on both followers’ self-evaluation of their abilities as well as on their perception of the goals’ attributes and – if so – whether these influences operate differently is an important question to answer in future research. Contradicting our assumption, goal importance did not mediate the impact of TLs on followers’ proactive behavior. Maybe, a strong sense of goal importance or commitment may thwart followers’ proactive behavior such that they solely focus on the goal on duty and behaviors directed at attaining this specific goal. In this case, positive effects on followers’ in-role performance are more likely to evolve than effects on their proactive behavior.

Theoretical Implications and Future Research

Integrating theorizing and research on self-regulated goal pursuit and personal goals with the goal setting of TLs, the present study broadens previous findings on the mechanisms of transformational leadership. Theoretically, it has widely been reasoned that TLs exert their influence on followers’ performance by increasing the importance of organizational goals and boosting followers’ feelings of being able to attain these goals, that way supporting followers’ goal pursuit. Empirical evidence on these deliberations, though, is still scarce. Our results show that TLs facilitate their followers’ goal striving by enhancing their perceptions of the importance and attainability of organizational goals.

The role of TLs within the goal setting process has first been analyzed by Kirkpatrick and Locke (1996) . In a laboratory simulation, they found that leaders’ visions affect followers’ performance to the extent that they inspire the setting of specific goals. These researchers, however, investigated quality goals only and the way they assessed goals induced specific (number of errors) rather than vague as well as self-set instead of assigned goals. In the following, Bono and Judge (2003) studied the influence of transformational leadership on followers’ goals among dyads of leaders and followers. They demonstrated that the more transformational supervisors lead, the more self-concordant (i.e., representative for personally held values) are the work goals followers set themselves. Like Kirkpatrick and Locke (1996) , also Bono and Judge (2003) focused on followers’ self-generated goals rather than examining the impact of TLs on the organizational goals they set. Other work considered strategic goals disseminated by top management which were assessed and evaluated in qualitative research ( Berson and Avolio, 2004 ), related to an organization’s overall goal ( Wright et al., 2012 ), or did not specifically focus on goals but rather on the way a job is to be done in general ( Bronkhorst et al., 2015 ). The study by Colbert et al. (2008) , which also examined a goal’s importance, did not neither refer to goals, which decidedly have been assigned by leaders. They analyzed broader goals, which in a pre-survey have been identified by CEOs to be relevant to the specific industry the research was conducted in (e.g., “Improving customer service” or “Improving the efficiency of internal operations”). Those studies, which indeed investigated organizational goals set by a leader, either viewed goal attributes to moderate the relation between transformational leadership and outcomes ( Whittington et al., 2004 ) or concentrated on the team level evaluation of these attributes ( Chi et al., 2011 ). In our research, we overcome some of these shortcomings: (1) We focused on two decisive goal attributes which have widely been neglected in the study of transformational leadership so far; (2) we concentrated on goals that have been set by leaders – the traditional basis of goal setting theory and one of the main tasks leaders have to complete; and (3) we ideographically assessed organizational goals and followers’ individual evaluations of these goals. Implementing these characteristics, we empirically emphasized goal attributes to be an important mechanism of transformational leadership.

Nevertheless, our findings are just the beginning of systematically bringing together evidence and theorizing on transformational leadership and goals. Future study efforts need to continue this integration. A first step to further intertwine these streams of research is to consider other goal attributes, which have been highlighted to affect the setting of goals (e.g., goal distance, goal orientation, feedback; Locke and Latham, 2002 ). With regard to followers’ self-efficacy, an important moderator within the goal setting theory, an extensive body of evidence has already been accumulated showing TLs to boost followers’ beliefs in their own (work-related) capabilities (e.g., Pillai and Williams, 2004 ; Liu et al., 2010 ; Den Hartog and Belschak, 2012 ). In addition to considering further mediators and moderators of goal setting, the goal attributes importance and attainability need to be assessed in more detail (e.g., Brunstein, 1993 ) than we did here.

Moreover, considering the statement by Howell and Shamir (2005) that “leaders and followers both play an active role in shaping their mutual relationships, and therefore shaping organizational outcomes” (p. 108) we argue for a leader-follower-fit perspective in future research. The underlying notion of such a perspective is that leaders should tailor their behavior to suit their followers’ needs. Regarding the regulation of one’s goal striving, individuals have certain preferences how to pursue goals (assessment or locomotion regulatory mode) as well as preferences for a desired or undesired end state (promotion or prevention regulatory focus; Higgins, 2000 , 2002 ). The link between transformational leadership and employees’ regulatory mode has already been examined empirically ( Benjamin and Flynn, 2006 ). Results demonstrate that followers with more of a locomotion regulatory mode (i.e., desire to move from one state to another) were more affected by TLs than followers with more of an assessment mode (i.e., desire to make comparisons and judgments before acting and appraising performance against standards). This seems to be the case as TLs tend to emphasize movement from state to state. Furthermore, there is evidence that the positive effects of articulating a vision are contingent on follower regulatory focus . In two experiments Stam et al. (2010) showed that visions focusing on preventing an undesirable situation lead to better performance than visions focusing on promoting a desirable situation for more prevention-focused followers (who want to avoid failures and fears), while the reverse was true for more promotion-focused followers (who want to reach success and ideals). The fit between followers’ regulatory mode and focus should therefore be further investigated as possible moderator in the interplay of transformational leadership behaviors and followers’ goal striving.

The congruence of leaders’ and followers’ goal appraisals should also be examined. If leaders set their followers goals, an individual redefinition process starts by which followers convert external tasks into internal ones ( Hackman, 1970 ; Hacker, 1982 ). Employees might be successful in striving for reinterpreted goals, which, in turn, may foster proactive behavior. The question, however, arises whether followers work on the task intended by the leader or whether the redefinition process leads them to work toward goals their leaders never wanted them to pursue. Therefore, research to come should not only assess followers’ evaluation of the goals they have been assigned, but should also consider whether leaders and followers agree upon the content of the goals, which are to be attained.

Just like in everyday life (cf. Austin and Vancouver, 1996 ), also at work individuals have to simultaneously pursue multiple goals. While acting on the attainment of one goal, employees scan the environment for opportunities to act on the other goals. This may lead to deferrals and reprioritizations of goals of which leaders are unaware. In the field of close relationships, Brunstein et al. (1996) showed that being aware of one’s partners’ goals, significantly influences the association among goal-related support and judgments of marital satisfaction. Only if participants were aware of their partners’ goals, the provision of goal-related support was significantly associated with their partners’ satisfaction. Transferring these findings to the field of leader-follower-interactions, it seems fruitful to explore whether leaders have to know which particular goal their followers actually strive for and how they progress in order to provide the most effective support. As, however, followers and leaders commonly share a more task-oriented relationship than couples, followers might feel controlled instead of empowered under this condition.

Managerial Implications

Due to its well-established positive impact, transformational leadership has become a prevalent topic in leadership education within business schools throughout the world ( Tourish et al., 2010 ). In small and medium-sized enterprises, however, leaders are rarely recruited from business schools, but rather are promoted into leadership positions based on their technical and professional expertise or the seniority principle. Such leaders often lack knowledge in managing and leading others as well as various skills necessary in successfully facilitating their followers’ goal pursuit. Therefore, they have to be equipped with leadership skills, which are relevant in effectively managing the goal setting process. Previous research has shown that transformational leadership behaviors can be developed in courses or training programs (e.g., Kelloway et al., 2000 ; Dvir et al., 2002 ). Such interventions may be tailored to specifically target the dissemination and pursuit of organizational goals. Trainings may start with an examination of the implicit theories of effective leadership and goal setting these leaders have in mind. Via 270- or 360-degree appraisal, they may be given insights into their own leadership behaviors and the way they are perceived by supervisors, colleagues, followers, and – should the occasion arise – customers. These analyses may be used as a starting point to improve the leaders’ behaviors as leaders may deduce a need for development by comparing their ideals and the way they are perceived.

As an important learning goal, leadership trainings need to convey that the manner in which goals are communicated impacts the degree of importance followers attach to these goals. Frese et al. (2003) developed and evaluated an action theory based training to teach participants the inspirational communication of a vision. The training consisted of two components. On the one hand, participants had to develop a vision for their own department and to deliver an enthusiastic and inspiring speech propagating it. Based on feedback, the vision and the speech were constantly improved in further role-plays. On the other hand, participants were taught about the characteristics and the importance of visions. Relevant paralinguistic and content issues of charismatic visions were exemplified and situations in which the speech may be applied were discussed. As evaluation studies of this 1.5 days training module revealed good to excellent effect sizes ( Frese et al., 2003 ), it should be incorporated into broader leadership training programs. Empirical evidence revealed that visions tight to charismatic or transformational leadership among others present an optimistic picture of the future, express confidence that the vision is attainable, or state the importance of followers’ participation ( Berson et al., 2001 ). Contingent reward leaders, by contrast, draw an instrumental vision tight to a specific time frame or linked to extrinsic benefits ( Sosik and Dinger, 2007 ). Thus, in order to be most effective, the particular themes a vision addresses deserve careful consideration within these trainings. Visions contain far-reaching, timeless, and relatively abstract ideas ( Berson et al., 2015 ), whereas goal setting theory found goals to work best if they are specific, challenging and timed ( Locke and Latham, 1990 ). In leading, however, both kinds are important ( Latham and Locke, 1991 ). Berson et al. (2015) reason that the motivational effect of visions vs. goals depends on the characteristics of the specific situation in which they are articulated or assigned: If leaders are socially and spatially proximate to their followers, greater effects result if more specific, time-constrained, and challenging goals are set. If, by contrast, leaders are socially and spatially distant, abstract, far-reaching, and timeless visions are a better means to stimulate followers’ performance. Attributes of the situation and properties of the message a leader delivers, thus need to fit in order to best motivate followers ( Berson et al., 2015 ). Accordingly, apart from learning to develop and articulate inspiring visions to increase the importance of organizational goals, training participants also need to learn about the goal setting theory and how goals need to be formulated and conveyed like it is already done in various transformational leadership trainings (e.g., Barling et al., 1996 ; Kelloway et al., 2000 ). In this context, leaders need to learn in which situations best to use either kind of communication strategy.

The communication of more concrete, challenging, and timed goals also helps to increase followers’ trust in being able to achieve the super-ordinate vision ( Berson et al., 2015 ). As such, modules on goal setting also serve in teaching leaders how to increase followers’ perception of an organizational goal’s attainability. Further behaviors, which lead followers to evaluate a goal to be attainable, also need to be developed and practiced in leadership trainings. Accordingly, leaders need to support followers and foster their impression of having control over the goal striving process as well as having several opportunities in achieving a certain goal. In order to increase followers’ perceptions of their control and opportunities, intellectual stimulation is an important leadership behavior. While training leaders, Barling et al. (1996) found this component of transformational leadership to be lowest among those participating in their intervention. To increase intellectually stimulating behaviors, participants were taught about the concept of transformational leadership, role-played these behaviors, and attained four monthly individual booster sessions with the researchers. In addition, leaders were encouraged to discuss new ideas with other training participants themselves in order to practice the behaviors they were meant to increase within their followers. Apart from intellectual stimulation, the information given, the role-plays, as well as the one-to-one coaching sessions also targeted the leaders’ individualized consideration. This behavior is important in fostering followers’ perception of supervisory support. As evidence on the effectiveness of this intervention, followers of those attending the training in sum rated their leaders higher on transformational leadership behaviors than those of a non-participating control group ( Barling et al., 1996 ). Training participants may further be encouraged to see things from their followers’ perspective and to anticipate potential obstacles followers might be confronted with during the goal pursuit. Based on that, leaders may be better able to provide support instrumental in achieving the goals they assign. As, compared to eclectic leadership trainings, transformational leadership trainings resulted in higher ratings of followers’ self-efficacy ( Dvir et al., 2002 ), such trainings should be helpful in increasing followers’ perception of being able to attain the goal their leaders set.

Several months after the initial training, a follow-up session could help to review the implementation of the behavior leaders learned during the training program, to exchange experiences with fellow trainees, and to revise leadership strategies aimed at increasing the importance and attainability of organizational goals. Fellow training participants could provide assistance and feedback on how to transfer the training content into daily work routines and how to deal with obstacles. Such booster sessions aim at maintaining the transfer of training for a longer period of time ( Saks and Belcourt, 2006 ). In sum, transformational leadership trainings have led to modest improvements across the following 2 years (see Bass, 1999 ).

Limitations

Despite these contributions, the present study has several limitations. First, our research was solely based on self-report data increasing the possibility of common method and social desirability bias ( Podsakoff and Organ, 1986 ). However, we consciously adopted this approach (see Conway and Lance, 2010 ) since all of our variables dealt with respondents’ personal cognition and affect. Obviously, respondents themselves are the most reliable and appropriate source of information in this particular case (cf. Chan, 2009 ). To avoid common method bias, leadership behaviors could have been analyzed as a self-report measure on the part of the leaders. In this study, though, we were interested in the perceptions of followers. Consistent with Walumbwa et al. (2007) we assert that leaders behave differently across situations and individuals or at least are perceived as behaving differently by those affected by these behaviors. Consequently, we actually examined whether differences in the perception of leadership account for variations in followers’ cognition and affect. Although it has been reasoned that the effects of common method variance are overstated ( Spector, 2006 ) and empirical evidence suggests they are leveled out by measurement errors ( Lance et al., 2010 ), we nevertheless collected data at two points in time and ensured participants’ anonymity to reduce possible response biases. Temporal separation of the assessment of predictors and outcomes is one of the procedural remedies suggested by Podsakoff et al. (2012) in order to control for common method biases. By introducing a time lag between these measurements, biases resulting from followers’ desire to appear consistent across responses as well as from demand characteristics related to the specific items may be attenuated ( Podsakoff et al., 2012 ).

The study design with its two temporally separated measurement occasions, however, is associated with a second limitation of the present work: the poor participation of respondents at the second time point and hence the high drop-out rate (cf. Podsakoff et al., 2012 ). High attrition rates and the associated risk of biased sample selection are particularly common when participants are recruited online and data is collected through the internet at more than one measurement occasion ( Kraut et al., 2004 ). The higher anonymity resulting from the web-based survey method might have caused a decrease in the response rate in our study. Participants did not feel as obliged to fill in the second part of the questionnaire, as they probably would have felt if the data had been collected in cooperation with a specific company. Moreover, we did not offer any kind of incentive, which might have increased the motivation to take part at T2. Nevertheless, we tested for systematic attrition and did not find any differences between respondents and non-respondents.

Although the two-wave study design helps in reducing potential biases resulting from common method variance, it is limited with regard to the examination of mediation effects ( Cohen et al., 2003 ): Based on such a design we may not readily draw rigorous causal inferences ( Cole and Maxwell, 2003 ). Even if we had adopted a sequential design and had added a third time point to measure transformational leadership, the goal attributes, and outcome variables at a distinct time point each, longitudinal mediation would not have been assessed more accurately ( Mitchell and Maxwell, 2013 ). Both designs fail to account for prior levels of the variables and thus for autoregressive effects, which indicate stable individual differences in a certain variable ( Preacher, 2015 ). In order to clarify the causal order of effects, longitudinal designs are needed which assess predictor, mediator, and outcome variables simultaneously at each of various measurement occasions ( Cole and Maxwell, 2003 ). Using such a design, we may rigorously examine the proposed mediating effects, contrast them with alternative causal models, and relate them to concurrent causal influences ( Cole and Maxwell, 2003 ). Given this deficiency in our study design, we have to be careful when interpreting our findings as evidence on the mediation model we assumed, because we may not rule out alternative causal effects. Experimental and training research, however, demonstrated an impact of transformational leadership on followers’ perception of related goal attributes (e.g., Bono and Judge, 2003 ) just as on the outcomes we considered (e.g., Barling et al., 1996 ). In the field of personal goals, Maier and Brunstein (2001) provided evidence based on longitudinal data that differences in the interplay between work-related goal commitment and goal attainability reliably predict changes in newcomers’ job satisfaction and job commitment during the first 8 months after organizational entry. In addition, goal effectiveness trainings designed to enhance students’ commitment to goals as well as their goal attainability perceptions improved the effectiveness of the students’ goal striving process and ultimately led to increases in their satisfaction with their studies ( Brunstein et al., 2008 ). Due to their respective designs, these studies allow for strong inferences on causality. The causal effects are in line with the mediation chain we proposed, and therefore reinforce our assumption that transformational leadership affects followers’ perceptions of goal attributes, which in turn exert an influence on their job-related attitudes and proactive behavior. Nonetheless, we recommend future research to further substantiate the impact of transformational leadership on followers’ job satisfaction, commitment, and proactive behavior via goal attributes longitudinally by drawing on cross-lagged panel or latent growth curve models or other currently emerging strategies to model longitudinal mediation (cf. Preacher, 2015 ).

An additional limitation of our study is that the data was collected in one specific (Western) culture. It is therefore uncertain whether our findings are generalizable across cultures. Given that a cultural influence may especially be assumed with regard to the visionary content transformational leaders convey ( House et al., 2004 ), particularly the impact of TLs on a goal’s importance may vary dependent on the vision theme that is being communicated within a certain culture. In order to yet strengthen the generalizability of our findings, we included a diverse sample representing a broad range of organizations and a variety of industries.

Finally, we cannot rule out that general perceptions of control or support at work might have influenced followers’ ratings of the goal attributes. Future research should consider constructs such as locus of control or decision latitude as well as a supportive organizational culture as influences on followers’ goal attribute perceptions.

Our study integrates research and theorizing on self-regulatory processes, goal setting, and personal goals in the context of transformational leadership. Although these constructs share certain overlap, they have traditionally been considered from different perspectives. The study empirically supports theoretical assumptions related to the effect of transformational leadership on followers’ goal pursuit showing that TLs influence the extent to which individuals perceive organizational goals as important and attainable. This is remarkable as leading through goals has originally been associated with a task-oriented leadership style according to which leaders set a specific goal, monitor its progress, and allocate rewards. We have learned that TLs exert their impact on followers’ job satisfaction, organizational commitment, and proactive behavior through the goal attributes importance and attainability. Findings suggest that these attributes are decisive in one’s goal striving no matter if a goal is self-set or assigned. However, both goal attributes differentially mediate the effect of transformational leadership. In sum, the present work thus contributes to the fields of leadership as well as goal research and their integration.

Author Contributions

BS and HK conceptualized the study with careful advice by GM. BS designed the study materials and collected the data. BS and HK processed the data. All authors were concerned with their analysis and interpretation. BS and HK drafted the earlier versions of the manuscript. GM thoroughly commented on these versions inducing further intellectual content. Before submitting the present work, BS substantially revised the manuscript.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We gratefully acknowledge the assistance of Melanie Hoff in collecting the data.

Funding. We acknowledge support for the Article Processing Charge by the Deutsche Forschungsgemeinschaft and the Open Access Publication Fund of Bielefeld University.

• Arnold K. A., Turner N., Barling J., Kelloway E. K., McKee M. C. (2007). Transformational leadership and psychological well-being: the mediating role of meaningful work. J. Occup. Health Psychol. 12 193–203. 10.1037/1076-8998.12.3.193 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Austin J. T., Vancouver J. B. (1996). Goal constructs in psychology: structure, process, and content. Psychol. Bull. 120 338–375. 10.1037/0033-2909.120.3.338 [ CrossRef ] [ Google Scholar ]
• Avolio B. J., Waldman D. A., Yammarino F. J. (1991). Leading in the 1990s: The four I′s of transformational leadership. J. Eur. Ind. Train. 15 9–16. 10.1108/03090599110143366 [ CrossRef ] [ Google Scholar ]
• Bandura A. (1997). Self-Efficacy. New York, NY: Freeman. [ Google Scholar ]
• Barling J., Weber J., Kelloway E. K. (1996). Effects of transformational leadership training on attitudinal and financial outcomes: a field experiment. J. Appl. Psychol. 81 827–832. 10.1037/0021-9010.81.6.827 [ CrossRef ] [ Google Scholar ]
• Bass B. M. (1985). Leadership and Performance Beyond Expectations. New York, NY: Free Press. [ Google Scholar ]
• Bass B. M. (1990). Bass & Stogdill’s Handbook of Leadership. New York, NY: Free Press. [ Google Scholar ]
• Bass B. M. (1999). Two decades of research and development in transformational leadership. Eur. J. Work Organ. Psychol. 8 9–32. 10.1080/135943299398410 [ CrossRef ] [ Google Scholar ]
• Bass B. M., Avolio B. J. (1994). Improving Organizational Effectiveness Through Transformational Leadership. Thousand Oaks, CA: Sage. [ Google Scholar ]
• Bass B. M., Riggio R. E. (2006). Transformational Leadership , 2nd Edn Mahwah, NJ: Erlbaum. [ Google Scholar ]
• Bateman T. S., Crant J. M. (1993). The proactive component of organizational behavior: a measure and correlates. J. Organ. Behav. 14 103–118. 10.1002/job.4030140202 [ CrossRef ] [ Google Scholar ]
• Benjamin L., Flynn F. J. (2006). Leadership style and regulatory mode: value from fit? Organ. Behav. Hum. Decis. Process. 100 216–230. 10.1016/j.obhdp.2006.01.008 [ CrossRef ] [ Google Scholar ]
• Berson Y., Avolio B. J. (2004). Transformational leadership and the dissemination of organizational goals: a case study of a telecommunication firm. Leadersh. Quart. 15 625–646. 10.1016/j.leaqua.2004.07.003 [ CrossRef ] [ Google Scholar ]
• Berson Y., Halevy N., Shamir B., Erez M. (2015). Leading from different psychological distances: a construal-level perspective on vision communication, goal setting, and follower motivation. Leadersh. Quart. 26 143–155. 10.1016/j.leaqua.2014.07.011 [ CrossRef ] [ Google Scholar ]
• Berson Y., Shamir B., Avolio B. J., Popper M. (2001). The relationship between vision strength, leadership style, and context. Leadersh. Quart. 12 53–73. 10.1016/S1048-9843(01)00064-9 [ CrossRef ] [ Google Scholar ]
• Bono J. E., Judge T. A. (2003). Self-concordance at work: toward understanding the motivational effects of transformational leaders. Acad. Manage. J. 46 554–571. 10.2307/30040649 [ CrossRef ] [ Google Scholar ]
• Bronkhorst B., Steijn B., Vermeeren B. (2015). Transformational leadership, goal setting, and work motivation: the case of a Dutch municipality. Rev. Public Pers. Administrat. 35 124–145. 10.1177/0734371X13515486 [ CrossRef ] [ Google Scholar ]
• Brunstein J. C. (1993). Personal goals and subjective well-being: a longitudinal study. J. Pers. Soc. Psychol. 65 1061–1070. 10.1037/0022-3514.65.5.1061 [ CrossRef ] [ Google Scholar ]
• Brunstein J. C., Dangelmayer G., Schultheiss O. C. (1996). Personal goals and social support in close relationships: effects on relationship mood and marital satisfaction. J. Pers. Soc. Psychol. 71 1006–1019. 10.1037/0022-3514.71.5.1006 [ CrossRef ] [ Google Scholar ]
• Brunstein J. C., Dargel A., Glaser C., Schmitt C. H., Spörer N. (2008). Persnliche Ziele im Studium: Erprobung einer Intervention zur Steigerung der Zieleffektivität und Zufriedenheit im Studium [Personal goals in college education: testing an intervention to increase students’ goal effectiveness and satisfaction in college]. Z. Pädagog. Psychol. 22 177–191. 10.1024/1010-0652.22.34.177 [ CrossRef ] [ Google Scholar ]
• Brunstein J. C., Schultheiss O. C., Maier G. W. (1999). “The pursuit of personal goals: a motivational approach to well-being and life-adjustment,” in Action and Development: Theory and Research Through the Life Span , eds Brandstädter J., Lerner R. M. (Thousand Oaks, CA: Sage; ), 169–196. [ Google Scholar ]
• Chan D. (2009). “So why ask me? Are self-report data really that bad?,” in Statistical and Methodological Myths and Urban Legends: Received Doctrine, Verity, and Fable in the Organizational and Social Science , eds Lance C. E., Vandenberg R. J. (Mahwah, NJ: Erlbaum; ), 311–338. [ Google Scholar ]
• Chi N. W., Chung Y. Y., Tsai W. C. (2011). How do happy leaders enhance team success? The mediating roles of transformational leadership, group affective tone and team processes. J. Appl. Soc. Psychol. 41 1421–1454. 10.1111/j.1559-1816.2011.00767.x [ CrossRef ] [ Google Scholar ]
• Cohen J., Cohen P., West S. G., Aiken L. S. (2003). Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences , 3rd Edn Mahwah, NJ: Erlbaum. [ Google Scholar ]
• Colbert A. E., Kristof-Brown A. L., Bradley B. H., Barrick M. R. (2008). CEO transformational leadership: the role of goal importance congruence in top management teams. Acad. Manage. J. 51 81–96. 10.5465/AMJ.2008.30717744 [ CrossRef ] [ Google Scholar ]
• Cole D. A., Maxwell S. E. (2003). Testing mediational models with longitudinal data: questions and tips in the use of structural equation modeling. J. Abnorm. Psychol. 112 558–577. 10.1037/0021-843X.112.4.558 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Conger J. A. (1999). Charismatic and transformational leadership in organizations: an insider’s perspective on these developing streams of research. Leadersh. Quart. 10 145–179. 10.1016/S1048-9843(99)00012-0 [ CrossRef ] [ Google Scholar ]
• Conger J. A., Kanungo R. N. (1998). Charismatic Leadership in Organizations. Thousand Oaks, CA: Sage. [ Google Scholar ]
• Conway J. M., Lance C. E. (2010). What reviewers should expect from authors regarding common method bias in organizational research. J. Bus. Psychol. 25 325–334. 10.1007/s10869-010-9181-6 [ CrossRef ] [ Google Scholar ]
• Cordery J., Sevastos P., Mueller W., Parker S. (1993). Correlates of employee attitudes toward functional flexibility. Hum. Relat. 46 705–723. 10.1177/001872679304600602 [ CrossRef ] [ Google Scholar ]
• Den Hartog D. N., Belschak F. D. (2012). When does transformational leadership enhance employee proactive behavior? The role of autonomy and role breadth self-efficacy. J. Appl. Psychol. 97 194–202. 10.1037/a0024903 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dvir T., Eden D., Avolio B. J., Shamir B. (2002). Impact of transformational leadership on follower development and performance: a field experiment. Acad. Manage. J. 45 735–744. 10.2307/3069307 [ CrossRef ] [ Google Scholar ]
• Emmons R. A. (1986). Personal strivings: an approach to personality and subjective well-being. J. Pers. Soc. Psychol. 51 1058–1068. 10.1037//0022-3514.51.5.1058 [ CrossRef ] [ Google Scholar ]
• Frese M., Beimel S., Schoenborn S. (2003). Action training for charismatic leadership: two evaluations of studies of a commercial training module on inspirational communication of a vision. Pers. Psychol. 56 671–697. 10.1111/j.1744-6570.2003.tb00754.x [ CrossRef ] [ Google Scholar ]
• Fuller J. B., Patterson C. E. P., Hester K. I. M., Stringer D. Y. (1996). A quantitative review of research on charismatic leadership: psychological reports. Psychol. Rep. 78 271–287. 10.2466/pr0.1996.78.1.271 [ CrossRef ] [ Google Scholar ]
• Gordon A., Yukl G. (2004). The future of leadership research: challenges and opportunities. Ger. J. Hum. Resour. Res. 18 359–365. 10.1177/239700220401800307 [ CrossRef ] [ Google Scholar ]
• Hacker W. (1982). “Action control. On the task dependent structure of action-controlling mental representations,” in Cognitive and Motivational Aspects of Action , eds Hacker W., Volpert W., Cranach M. (Berlin: Deutscher Verlag der Wissenschaft; ), 137–149. [ Google Scholar ]
• Hackman J. R. (1970). “Tasks and task performance in research on stress,” in Social and Psychological Factors in Stress , ed. J. E. McGrath. (New York, NY: Holt, Reinhart & Winston; ), 202–237. [ Google Scholar ]
• Hayes A. F. (2013). Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. New York, NY: The Guilford Press. [ Google Scholar ]
• Heckhausen H., Kuhl J. (1985). “From wishes to action: the dead ends and short cuts on the long way to action,” in Goal-Directed Behavior: Psychological Theory and Research on Action , eds Frese M., Sabini J. (Hillsdale, NJ: Erlbaum; ), 134–160. [ Google Scholar ]
• Heinitz K., Rowold J. (2007). Gütekriterien einer deutschen Adaptation des Transformational Leadership Inventory (TLI) von Podsakoff [Psychometric properties of a German adaptation of the Transformational Leadership Inventory (TLI) by Podsakoff]. Z. Arbeits- Organisationspsychol. 51 1–15. 10.1026/0932-4089.51.1.1 [ CrossRef ] [ Google Scholar ]
• Higgins E. T. (2000). Making a good decision: value from fit. Am. Psychol. 55 1217–1230. 10.1037/0003-066X.55.11.1217 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Higgins E. T. (2002). How self-regulation creates distinct values: the case of promotion and prevention decision making. J. Consum. Psychol. 12 : 177 10.1207/S15327663JCP1203_01 [ CrossRef ] [ Google Scholar ]
• Hochwarter W. A., Perrewé P. L., Ferris G. R., Brymer R. A. (1999). Job satisfaction and performance: the moderating effects of value attainment and affective disposition. J. Vocat. Behav. 54 296–313. 10.1006/jvbe.1998.1659 [ CrossRef ] [ Google Scholar ]
• Hollenbeck J. R., Klein H. J. (1987). Goal commitment and the goal-setting process: problems, prospects, and proposals for future research. J. Appl. Psychol. 72 212–220. 10.1037/0021-9010.72.2.212 [ CrossRef ] [ Google Scholar ]
• Hollenbeck J. R., Williams C. R. (1987). Goal importance, self-focus and the goal-setting process. J. Appl. Psychol. 72 204–211. 10.1037/0021-9010.72.2.204 [ CrossRef ] [ Google Scholar ]
• House R. J., Hanges P. J., Javidan M., Dorfman P. W., Gupta V. (2004). Culture, Leadership, and Organizations: The GLOBE Study of 62 Societies. Thousand Oaks, CA: Sage. [ Google Scholar ]
• Howell J. M., Shamir B. (2005). The role of followers in the charismatic leadership process: relationships and their consequences. Acad. Manage. Rev. 30 96–112. 10.2307/20159097 [ CrossRef ] [ Google Scholar ]
• Humphrey S. E., Nahrgang J. D., Morgeson F. P. (2007). Integrating motivational, social, and contextual work design features: a meta-analytic summary and theoretical extension of the work design literature. J. Appl. Psychol. 92 1332–1356. 10.1037/0021-9010.92.5.1332 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Judge T. A., Piccolo R. F. (2004). Transformational and transactional leadership: a meta-analytic test of their relative validity. J. Appl. Psychol. 89 755–768. 10.1037/0021-9010.89.5.755 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kark R., Shamir B., Chen G. (2003). The two faces of transformational leadership: empowerment and dependency. J. Appl. Psychol. 88 246–255. 10.1037/0021-9010.88.2.246 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Karoly P. (1993). Mechanisms of self regulation: a systems view. Annu. Rev. Psychol. 44 23–52. 10.1146/annurev.ps.44.020193.000323 [ CrossRef ] [ Google Scholar ]
• Kelloway E. K., Barling J., Helleur J. (2000). Enhancing transformational leadership: the roles of training and feedback. Leadersh. Organ. Dev. J. 21 145–149. 10.1108/01437730010325022 [ CrossRef ] [ Google Scholar ]
• Kirkpatrick S. A., Locke E. A. (1996). Direct and indirect effects of three core charismatic leadership components on performance and attitudes. J. Appl. Psychol. 81 36–51. 10.1037/0021-9010.81.1.36 [ CrossRef ] [ Google Scholar ]
• Klug H. J. P., Maier G. W. (2015). Linking goal progress and subjective well-being: a meta-analysis. J. Happin. Stud. 16 37–65. 10.1007/s10902-013-9493-0 [ CrossRef ] [ Google Scholar ]
• Kraut R., Olson J., Banaji M., Bruckman A., Cohen J., Couper M. (2004). Psychological research online: report of board of scientific affairs’ advisory group on the conduct of research on the internet. Am. Psychol. 59 105–117. 10.1037/0003-066X.59.2.105 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lance C. E., Dawson B., Birkelbach D., Hoffman B. J. (2010). Method effects, measurement error, and substantive conclusions. Organ. Res. Methods 13 435–455. 10.1177/1094428109352528 [ CrossRef ] [ Google Scholar ]
• Latham G. P., Locke E. A. (1991). Self-regulation through goal setting. Organ. Behav. Hum. Decis. Process. 50 212–247. 10.1016/0749-5978(91)90021-K [ CrossRef ] [ Google Scholar ]
• Latham G. P., Saari L. M. (1979). Importance of supportive relationships in goal settings. J. Appl. Psychol. 64 151–156. 10.1037//0021-9010.64.2.151 [ CrossRef ] [ Google Scholar ]
• Lee C., Bobko P., Earley P. C., Locke E. A. (1991). An empirical analysis of a goal setting questionnaire. J. Organ. Behav. 12 467–482. 10.1002/job.4030120602 [ CrossRef ] [ Google Scholar ]
• Liu J., Siu O.-L., Shi K. (2010). Transformational leadership and employee well-being: the mediating role of trust in the leader and self-efficacy. Appl. Psychol. Int. Rev. 59 454–479. 10.1111/j.1464-0597.2009.00407.x [ CrossRef ] [ Google Scholar ]
• Locke E. A., Latham G. P. (1990). A Theory of Goal Setting and Task Performance. Eaglewood Cliffs, NJ: Prentice Hall. [ Google Scholar ]
• Locke E. A., Latham G. P. (2002). Building a practically useful theory of goal setting and task motivation: a 35-year odyssey. Am. Psychol. 57 705–717. 10.1037/0003-066X.57.9.705 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Locke E. A., Latham G. P., Erez M. (1988). The determinants of goal commitment. Acad. Manage. Rev. 13 23–39. 10.5465/AMR.1988.4306771 [ CrossRef ] [ Google Scholar ]
• Lowe K. B., Kroeck K. G., Sivasubramaniam N. (1996). Effectiveness correlates of transformational and transactional leadership: a meta-analytic review of the MLQ literature. Leadersh. Quart. 7 385–425. 10.1016/S1048-9843(96)90027-2 [ CrossRef ] [ Google Scholar ]
• Lüdtke O., Trautwein U. (2007). Aggregating to the between-person level in idiographic research designs: personal goal research as an example of the need to distinguish between reliability and homogeneity. J. Res. Pers. 41 230–238. 10.1016/j.jrp.2006.03.005 [ CrossRef ] [ Google Scholar ]
• MacKinnon D. P., Lockwood C. M., Williams J. (2004). Confidence limits for the indirect effect: distribution of the product and resampling methods. Multivar. Behav. Res. 39 99–128. 10.1207/s15327906mbr3901_4 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• MacKinnon D. P., Warsi G., Dwyer J. H. (1995). A simulation study of mediated effect measures. Multivar. Behav. Res. 30 41–62. 10.1207/s15327906mbr3001_3 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Maier G. W., Brunstein J. C. (2001). The role of personal work goals in newcomers’ job satisfaction and organizational commitment: a longitudinal analysis. J. Appl. Psychol. 86 1034–1042. 10.1037/0021-9010.86.5.1034 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Maier G. W., Woschée R. M. (2002). Die affektive Bindung an das Unternehmen: Psychometrische Überprüfung einer deutschsprachigen Fassung des Organizational Commitment Questionnaire (OCQ) von Porter und Smith (1970) [Affective commitment to an organization: psychometric examination of a German version of the Organizational Commitment Questionnaire (OCQ) of Porter and Smith (1970)]. Z. Arbeits- Organisationspsychol . 46 126–136. 10.1026//0932-4089.46.3.126 [ CrossRef ] [ Google Scholar ]
• Menon S. T. (2001). Employee empowerment: an integrative psychological approach. Appl. Psychol. Int. Rev. 50 153–180. 10.1111/1464-0597.00052 [ CrossRef ] [ Google Scholar ]
• Meyer J. P., Stanley D. J., Herscovitch L., Topolnytsky L. (2002). Affective, continuance, and normative commitment to the organization: a meta-analysis of antecedents, correlates, and consequences. J. Vocat. Behav. 61 20–52. 10.1006/jvbe.2001.1842 [ CrossRef ] [ Google Scholar ]
• Mitchell M. A., Maxwell S. E. (2013). A comparison of the cross-sectional and sequential designs when assessing longitudinal mediation. Multivar. Behav. Res. 48 301–339. 10.1080/00273171.2013.784696 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mowday R. T., Steers R. M., Porter L. W. (1979). The measurement of organizational commitment. J. Vocat. Behav. 14 224–247. 10.1016/0001-8791(79)90072-1 [ CrossRef ] [ Google Scholar ]
• Mowday R. T., Steers R. M., Porter L. W. (1982). Employee-Organizational Linkages: The Psychology of Commitment, Turnover and Absenteeism. New York, NY: Academic Press. [ Google Scholar ]
• Neuberger O., Allerbeck M. (1978). Messung und Analyse von Arbeitszufriedenheit [Measurement and Analysis of Job Satisfaction]. Bern: Huber. [ Google Scholar ]
• Ng T. W. H., Sorensen K. L. (2008). Toward a further understanding of the relationships between perceptions of support and work attitudes: a meta-analysis. Group Organ. Manage. 33 243–268. 10.1177/1059601107313307 [ CrossRef ] [ Google Scholar ]
• Oettingen G., Pak H., Schnetter K. (2001). Self-regulation of goal setting: turning free fantasies about the future into binding goals. J. Pers. Soc. Psychol. 80 736–753. 10.1037/0022-3514.80.5.736 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Peng A. C., Lin H.-E., Schaubroeck J., Mcdonough E. F., Hu B., Zhang A. (2016). CEO intellectual stimulation and employee work meaningfulness: the moderating role of organizational context. Group Organ. Manage. 41 203–231. 10.1177/1059601115592982 [ CrossRef ] [ Google Scholar ]
• Pillai R., Williams E. A. (2004). Transformational leadership, self-efficacy, group cohesiveness, commitment and performance. J. Organ. Change Manage. 17 144–159. 10.1108/09534810410530584 [ CrossRef ] [ Google Scholar ]
• Podsakoff P. M., MacKenzie S. B., Moorman R. H., Fetter R. (1990). Transformational leader behaviors and their effects on followers’ trust in leader, satisfaction, and organizational citizenship behaviors. Leadersh. Quart. 1 107–142. 10.1016/1048-9843(90)90009-7 [ CrossRef ] [ Google Scholar ]
• Podsakoff P. M., MacKenzie S. B., Podsakoff N. P. (2012). Sources of method bias in social science research and recommendations on how to control it. Annu. Rev. Psychol. 63 539–569. 10.1146/annurev-psych-120710-100452 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Podsakoff P. M., Organ D. W. (1986). Self-reports in organizational research: problems and prospects. J. Manage. 12 531–544. 10.1177/014920638601200408 [ CrossRef ] [ Google Scholar ]
• Powers W. T. (1978). Quantitative analysis of purposive systems: some spadework at the foundations of scientific psychology. Psychol. Rev. 85 417–435. 10.1037/0033-295X.85.5.417 [ CrossRef ] [ Google Scholar ]
• Preacher K. J. (2015). Advances in mediation analysis: a survey and synthesis of new developments. Annu. Rev. Psychol. 66 825–852. 10.1146/annurev-psych-010814-015258 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Preacher K. J., Hayes A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav. Res. Methods 40 879–891. 10.3758/BRM.40.3.879 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Preacher K. J., Kelley K. (2011). Effect size measures for mediation models: quantitative strategies for communicating indirect effects. Psychol. Methods 16 93–115. 10.1037/a0022658 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ronan W. W., Latham G. P., Kinne S. B. (1973). Effects of goal setting and supervision on worker behavior in an industrial situation. J. Appl. Psychol. 58 302–307. 10.1037/h0036303 [ CrossRef ] [ Google Scholar ]
• Saks A. M., Belcourt M. (2006). An investigation of training activities and transfer of training in organizations. Hum. Resour. Manage. 45 629–648. 10.1002/hrm.20135 [ CrossRef ] [ Google Scholar ]
• Shamir B., House R. J., Arthur M. B. (1993). The motivational effects of charismatic leadership: a self-concept based theory. Organ. Sci. 4 577–594. 10.1287/orsc.4.4.577 [ CrossRef ] [ Google Scholar ]
• Sheldon K. M., Kasser T., Smith K., Share T. (2002). Personal goals and psychological growth: testing an intervention to enhance goal attainment and personality integration. J. Pers. 70 5–31. 10.1111/1467-6494.00176 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sosik J. J., Dinger S. L. (2007). Relationships between leadership style and vision content: the moderating role of need for approval, self-monitoring, and need for social power. Leadersh. Quart. 18 134–153. 10.1016/j.leaqua.2007.01.004 [ CrossRef ] [ Google Scholar ]
• Spector P. E. (2006). Method variance in organizational research. Organ. Res. Methods 9 221–232. 10.1177/1094428105284955 [ CrossRef ] [ Google Scholar ]
• Spreitzer G. M. (1995). Psychological empowerment in the workplace: dimensions, measurement, and validation. Acad. Manage. J. 38 1442–1465. 10.2307/256865 [ CrossRef ] [ Google Scholar ]
• Stajkovic A. D., Luthans F. (1998). Self-efficacy and work-related performance: a meta-analysis. Psychol. Bull. 124 240–261. 10.1037/0033-2909.124.2.240 [ CrossRef ] [ Google Scholar ]
• Stam D. A., van Knippenberg D., Wisse B. (2010). The role of regulatory fit in visionary leadership. J. Organ. Behav. 31 499–518. 10.1002/job.624 [ CrossRef ] [ Google Scholar ]
• Staufenbiel T., Hartz C. (2000). Organizational Citizenship Behavior: Entwicklung und erste Validierung eines Meßinstruments [Organizational citizenship behavior: development and validation of a measurement instrument]. Diagnostica 46 73–83. 10.1026//0012-1924.46.2.73 [ CrossRef ] [ Google Scholar ]
• Tett R. P., Guterman H. A., Bleier A., Murphy P. J. (2000). Development and content validation of a “hyperdimensional” taxonomy of managerial competence. Hum. Perform. 13 205–251. 10.1207/S15327043HUP1303_1 [ CrossRef ] [ Google Scholar ]
• Tourish D., Craig R., Amernic J. (2010). Transformational leadership education and agency perspectives in business school pedagogy: a marriage of inconvenience? Br. J. Manage. 21 : s40 10.1111/j.1467-8551.2009.00682.x [ CrossRef ] [ Google Scholar ]
• van Dierendonck D., Haynes C., Borrill C., Stride C. (2004). Leadership behavior and subordinate well-being. J. Occup. Health Psychol. 9 165–175. 10.1037/1076-8998.9.2.165 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Vancouver J. B. (2000). “Self-regulation in organizational settings: a tale of two paradigms,” in Handbook of Self-Regulation , eds Boekaerts M., Pintrich P., Zeidner M. (San Diego, CA: Academic Press; ), 303–341. 10.1016/B978-012109890-2/50039-1 [ CrossRef ] [ Google Scholar ]
• Viswesvaran C., Sanchez J. I., Fisher J. (1999). The role of social support in the process of work stress: a meta-analysis. J. Vocat. Behav. 54 314–334. 10.1006/jvbe.1998.1661 [ CrossRef ] [ Google Scholar ]
• Walumbwa F. O., Lawler J. J., Avolio B. J. (2007). Leadership, individual differences, and work-related attitudes: a cross-culture investigation. Appl. Psychol. 56 212–230. 10.1111/j.1464-0597.2006.00241.x [ CrossRef ] [ Google Scholar ]
• Wang G., Oh I., Courtright S. H., Colbert A. E. (2011). Transformational leadership and performance across criteria and levels: a meta-analytic review of 25 years of research. Group Organ. Manage. 36 223–270. 10.1177/1059601111401017 [ CrossRef ] [ Google Scholar ]
• Whittington J. L., Goodwin V. L., Murray B. (2004). Transformational leadership, goal difficulty, and job design: independent and interactive effects on employee outcomes. Leadersh. Quart. 15 593–606. 10.1016/j.leaqua.2004.07.001 [ CrossRef ] [ Google Scholar ]
• Wright B. E., Moynihan D. P., Pandey S. K. (2012). Pulling the levers: transformational leadership, public service motivation, and mission valence. Public Administrat. Rev. 72 206–215. 10.1111/j.1540-6210.2011.02496.x [ CrossRef ] [ Google Scholar ]
• Yousef D. A. (2000). Organizational commitment and job satisfaction as predictors of attitudes toward organizational change in a non-western setting. Pers. Rev. 29 567–592. 10.1108/00483480010296401 [ CrossRef ] [ Google Scholar ]

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Team Science and Transformational Leadership in the Healthcare Field

Elizabeth Hustead

Introduction Complex healthcare environments, such as large, geographically dispersed hospital networks, specialized treatment centers, and research facilities, require strong leadership with multidisciplinary teams of healthcare professionals and scientists to work towards solutions (Stokols et al, 2008; Gadlin et al., 2010; Vogel et al., 2013; NRC, 2015). Modern healthcare problems cannot be solved in the traditional, linear manner because as new solutions to the problem are considered, the definition of the problem evolves (Stokols et al., 2008). A complex healthcare question, such as how to improve patient outcomes while reducing burden on a hospital, requires healthcare experts from many disciplines working together under the appropriate leadership. Having input from these healthcare professionals is vital in reaching a long-term, meaningful solution; each brings their own unique perspective based on their area of expertise (Stokols et al., 2005). Having the appropriate leadership in place is critical to a team’s success and productivity. Without the correct leadership at the helm, even teams of the brightest professionals can run aground or flounder. As treatment centers and patient care become more complex, the need for collaborative research, team science, and team leadership will continue to grow.

This chapter describes the current state of team science and collaborative patient care in the field of healthcare. Using classic papers on collaboration, team science, and transformational leadership, we will review and critique several large-scale team science initiatives in the healthcare field from the Cleveland Clinic to Aligning Forces for Quality Program. We will also discuss the transformational leadership aspects of each initiative and how those leadership tactics contributed to the programs’ overall success. Based on the current literature and the state of the science, recommendations will be made on the direction of future research in the healthcare field. The reader should finish the chapter with a thorough understanding of prior team science healthcare interventions and how transformational leadership can be employed to effect change at both the individual and team levels.

Background One approach to solving complex modern organizational problems, including those in the field of healthcare, is called team science: a collaborative, multidisciplinary research process that brings independent researchers or healthcare professionals together into a collaborative group (Gadlin et al., 2010, Vogel et al., 2013; NRC, 2015). This has been a natural fit for healthcare organizations, such as hospitals or public health departments, as they shift their focus from disease treatment to preventative, whole patient care, and populations health (Zocchi et al., 2015). One example of this shift took place during the 2007 reorganization of the Cleveland Clinic, which will be discussed in further later in the chapter.

Team Science Overview The past 20 years have seen a surge of investments into team science programs in innovation, research, and advancements in patient care. This kind of approach was often not possible within a single healthcare system working in isolation, but is now being explored through teams of healthcare professionals working together (Stokols, 2008). Healthcare research into organizations is further complicated by the fast-paced nature of technological advancement in modern medicine and public health. New technology is emerging every day that can improve patient outcomes and streamline hospital procedures. For example, how can healthcare facilities decide which changes to pursue and which technologies to implement? This question can often seem overwhelming and is often unaddressed by healthcare facilities large or small, who have their hands full managing patient care and trying to stay financially solvent. This combination of circumstances often results in the same practices continuing for decades because that’s “how things have always been done” even if more efficient or innovative methods emerge. Implementing team science is one way to bring large healthcare organizations into the future and explore benefits for patients, healthcare professionals, and the infrastructure of the healthcare system itself.

Challenges for Team Science While team science has many advantages, there are also many challenges. Highly diverse team membership can create issues for research; there are cultural, linguistic, and institutional barriers to everyday interactions and long-term collaborations (Vogel et al., 2013; NRC, 2015). Deep knowledge integration presents difficulties as well; it challenges team members to share and build on each other’s knowledge across boundaries and disciplines (Olson & Olson, 2008).

Boundaries in the healthcare field are also permeable and goals or priorities themselves can change over time, resulting in an ever-changing landscape that is difficult for healthcare teams to navigate. Additionally, team membership often fluctuates as healthcare professionals join or leave the team. Finally, geographic dispersion can be a significant barrier to disseminating innovations evenly, particularly with communication and coordination (teams in different locations have little face-to-face interactions and different time zones necessitate additional planning to determine convenient meeting times for all parties) (Borgman et al., 2008; Olson & Olson, 2008). Overcoming these obstacles can be difficult, but not impossible, with the appropriate tools in place to facilitate communication.

Communication is the common theme that unites complex modern research problems and collaborative solutions. One of the main determinants of the collaborative capacity (and thus potential success) of a healthcare team are the technological resources and organizational support that allow team members to network data over the course of a project (McGrath & Hollingshead, 1994; Majchrzak et al., 2000; Olson & Olson, 2008; Stokols, 2008). Working collaboratively, even within a single department or hospital, can be a challenging and when departmental or institutional boundaries are crossed, these challenges increase (Borgman, 2008; DeSanctis & Jackson, 1994, Galdin et al., 2010).

The National Institute of Health (NIH) 2010 Team Science Field Guide states that one of the biggest challenges facing new cross-organizational teams is that there are no procedures or infrastructure in place to facilitate these interactions (Galdin et al., 2010). This lack of infrastructure can be crippling to a healthcare network, particularly one that is new to team science and seeking to implement changes for the first time (Borgman, 2008; DeSanctis & Jackson, 1994, Galdin et al., 2010). These challenges will be addressed in this chapter and several cases of healthcare organizations who have attempted to implement these changes will be analyzed.

Context In this chapter, we will address the context in which team science can be integrated into the healthcare field to improve outcomes such as hospital efficiency, patient satisfaction, and hospital costs. The NIH Field Guide describes team science as “a collaborative and often cross-disciplinary approach to scientific inquiry that draws researchers who otherwise work independently or as coinvestigators on smaller-scale projects into collaborative centers and groups.” Team science requires strong and effective leadership to ensure a high-functioning, effective team. Most research on this topic focuses on transformational leadership, a leadership style that “induce[s] followers to transcend their interests for a greater good” (Kozloqski & Ilgen, 2006). There are myriad benefits to working with teams with strong leadership, particularly in healthcare or public health settings which by their very nature are interdisciplinary.

Puga et al. state that using transdisciplinary teams in healthcare “brings together a diverse group of individuals who fully integrate theories, methodologies, and frameworks from their respective fields to work as a cohesive unit on complex issues.” By working in teams, individuals are able to pool both physical and intellectual resources to “draw on multiple disciplines, fields, and professions” (Vogel et al, 2013). In research science, this results in more advanced and comprehensive interdisciplinary studies; in the field of healthcare, this results in a more comprehensive approach to patient wellness. Team science is a natural fit for healthcare systems such as the Cleveland Clinic where major restructuring organized healthcare professionals by organ system to improve patient care (Porter & Teisberg, 2016). Coordinating large scale healthcare systems and disseminating information through or planning improvements for those systems is also a task well suited to the team science structure (Zocchi et al., 2015; Porter & Teisberg, 2016). While team science is a valuable tool in healthcare settings, significant improvements need to be made in both the resources and support available for healthcare systems in order to further incorporate team science.

Healthcare Team Science and Transformational Leadership Trans- or interdisciplinary teams are extremely valuable in the field of healthcare, as they “bring together a diverse group of individuals who fully integrate theories, methodologies, and frameworks from their respective fields to work as a cohesive unit on complex issues” (Puga et al., 2013). In a thorough literature review conducted by Buscemi et al., researchers recommend that a stronger emphasis be put on collaboration and teamwork between health professionals (2012). The results of those studies indicate that interdisciplinary teams can yield more positive patient outcomes and that inter-professional collaboration is most effective when all professionals treat each other’s opinions with respect and communicate well (Buscemi et al., 2012). Because respect and communication are not always a given, the authors encourage evaluation and preparation for collaboration before the team is launched.

Team science is supported by several studies on transformational leadership. In their meta-analytic review, Wang et al. found that transformational leadership was “positively related to individual-level follower performance” and that strong leadership contributed positively to productivity outcomes at several levels (2011). The National Academy of Sciences corroborates these findings with their handbook “Enhancing the Effectiveness of Team Science” and states that transformational leadership approach facilitates “subordinate motivation and effort” and that effective transformational leadership often results in better outcomes at the team and individual levels than other leadership strategies (2015). There is a general consensus that future research is needed to analyze the efficacy of interdisciplinary teams and leadership (specifically transformational leadership) in the healthcare field and that additional tools should be developed to facilitate these goals.

Case Studies in Healthcare Team Science and Transformational Leadership Aligning Forces for Quality Case Study In their 2015 study, Zocchi at al. further examine the need for improved leadership and teamwork in a field of healthcare (emergency medicine, specifically) and implements and analyzes such extensive changes. For this study, 172 interventions were implemented across 42 hospitals as part of the Aligning Forces for Quality program. Two-thirds (28) of the hospitals from the study saw improvement on one or more metrics. Many of the truly impressive changes achieved through this study (reduction in patient wait time, rates of patients who left without being seen, unnecessarily long stays, etc.) were improved through changes in leadership and the introduction of teams, even if only for educational and not collaborative purposes.

While important improvements for a number of hospitals were made, one-third of the hospitals enrolled in the study did not show improvements, and 40 of the initial 82 hospitals who signed up to participate in the Aligning Forces for Quality program dropped out of the study, convinced that they could not make the changes necessary. More work needs to be done to help hospitals prepare for large-scale changes and incorporating teams. One of the main challenges reported was a lack of buy-in from senior leadership and lackluster support for the “change champions” using transformational leadership strategies to implement the Aligning Forces for Quality program (Zocchi at al., 2015).

The authors suggest that one explanation is the lack of face-to-face meetings, resulting in reduced engagement and a lack of leadership opportunities, despite the transformational leadership style of team leaders (Zocchi at al., 2015). Zocchi et al. suggest that for future interventions team leaders of healthcare works should be more involved at the planning stage, so as to decrease staff resistance to change (2015). The authors also state that improved transformational leadership is necessary to early success of the program to even get the intervention started (2015).

Cleveland Clinic Case Study In their review of the changes made at the Cleveland Clinic for the Harvard Business School Case, Porter and Treisberg emphasize the importance of working in teams with strong transformational leadership. After Delos M. Cosgrove, M.D. became the Clinic’s CEO in October 2004, he instituted many changes starting with a stronger emphasis on patient care and satisfaction and a drive for unified clinical leadership. He also reorganized departments from medical/surgical classifications to teams focused on specific organs or organ systems and developed 106 “Care Pathways.” While this initiative began as a way to improve the patient experience, it blossomed into the formation of multidisciplinary care teams lead by transformational leaders who were more cost and time efficient while also delivering a better patient experience. As a result, operating costs for the Clinic decreased, patient satisfaction increased, and several other major hospital systems began adopting this model.

Incorporating transformational leadership into the Cleveland Clinic re-organization was largely responsible for its success. Team were made up of “caregivers” (formerly referred to as non-professional staff) who work together in teams to discuss the mission, values, and patient experience. Data was collected from these teams on day-to-day hospital operations so that action items could be set at the team level for continued improvement (Porter & Treisberg, 2016). Known as “Leadership Rounding,” this process encouraged all caregivers to take ownership in the success of the Clinic and patient satisfaction. The re-organization of the Cleveland Clinic clearly demonstrates the value of using teams of dedicated professionals and non-professional staff lead by transformational leaders in the field of healthcare.

Personal relevance Working for SNAP-Ed (the Supplemental Nutrition Assistance Program- Education) requires a significant amount of interdisciplinary collaboration. SNAP-Ed serves low income audiences across the country and Ohio (ranked 6th in food insecurity in the nation) has a great need for that guidance. SNAP-Ed is housed in the Family and Consumer Sciences (FCS) branch of Extension at the Ohio State University. Within Extension, SNAP-Ed works collaboratively with the other Extension branches: Community Development, Agriculture and Natural Resources, and 4-H (youth programming).

Internal Transdisciplinary Teamwork Each branch of Extension comes with their own priorities and areas of expertise. While the overarching goal of all Extension branches is to serve Ohioans, it can be challenging to work together because SNAP-Ed is required to focus exclusively on low income populations with very strict programmatic guidelines. These difficulties are compounded by the fact that each county in Ohio has an Extension office, each with their own Extension specialists, Program Coordinators, and Program Assistants. Because Extension personnel are intentionally geographically dispersed to better serve Ohio’s diverse population, tools to enhance long-distance collaboration are desperately needed. In this vein, OSU Extension leadership have implemented several initiatives, including a major restructuring, an annual Extension conference, and the adoption of the Zoom collaborative software platform.

Within FCS, SNAP-Ed works collaboratively with other Community Nutrition programs, including EFNEP (the Expanded Food, Nutrition, and Education Program), Farm to School, and Healthy Living programs (including Healthy Relationships and Healthy Finances). While each of these teams fall under the umbrella of Community Nutrition programs and are overseen by a single Associate Dean, they serve different audiences in different contexts in different settings across the state. While the shared focus and the fact that all Community Nutrition programs are housed on OSU campus make collaboration somewhat easier, there are still the typical challenges experienced by any diverse, interdisciplinary team.

External Transdisciplinary Teamwork External transdisciplinary teamwork is also a critical facet of SNAP-Ed’s outreach and success. SNAP-Ed was a founding member of the Ohio State Nutrition Action Committee (SNAC) and has spearheaded several innovation projects on behalf of SNAC. Most recently, SNAP-Ed launched a social marketing campaign, Celebrate Your Plate, with the support of SNAC members including the Ohio Department of Health (WIC and Creating Healthy Communities), Ohio Department of Education, Ohio Department of Aging, Ohio Department of Job and Family Services, EFNEP, and the Mid-Ohio Foodbank.

The success of this social marketing initiative is dependent on strong teamwork and communication between SNAC members to disseminate messages and materials across the state. External (and in this case inter-agency) collaboration at the state level can be complicated, even when team members are all highly motivated and working towards the same goal. There is often a disconnect between the implementing agency (in this case, SNAP-Ed) who needs to make the day-to-day decisions about the project and other team members. Additionally, SNAC is made up of one state-level representative of many government or non-profit agencies, so decisions that need to be approved by the various SNAC partners or regional level officials delay progress significantly. These challenges to transdisciplinary team science are being evaluated via a process evaluation so that changes can be made in the future to enhance collaboration.

Discussion The field of healthcare, including public health, is becoming increasingly complex with the introduction of new technology and scientific developments. Complex problems, such as how to improve patient outcomes while reducing burden on a hospital, requires healthcare experts from many disciplines lead by an individual practicing transformational leadership. As we observed with the Cleveland Clinic case study, these challenges exist within a single hospital or healthcare system.

New leadership and teamwork strategies, such as team science, are essential to the continued success, development, and expansion of healthcare-related services. Having input, guidance, and pooled knowledge from a team of healthcare professionals allows team members to combine their expertise to achieve solutions far beyond what would have been capable with those individuals working in silos. When team science is combined with transformational leadership, the level of success increases exponentially. This transformational team science approach is a logical fit for healthcare and other public health organizations as healthcare problems have become more complex over time and require more advanced resources to resolve. In public health the utility of this approach is even more pronounced as the focus has shifted over the past century from disease treatment to disease prevention.

We used the Cleveland Clinic case study and the Aligning Forces for Quality Program to demonstrate that there is significant interest in using team science and transformational leadership to improve healthcare systems. In both cases, major changes were made to improve the patient experience as well as hospital functioning metrics. However, is it possible to apply these strategies to other healthcare systems? Would the Cleveland Clinic restructuring have been as successful without such strong support from management and administrative professionals within the hospital? Porter and Treisberg cite examples of how the strategies employed by the Cleveland Clinic have been implemented in other hospital networks. This indicates some potential for replicating these results in other systems, but without the administrative support and a significant amount of financial support this major restructuring would not have been possible.

Based on the literature and studies reviewed in this chapter, we can conclude that team science can be successfully applied to healthcare settings if certain conditions are met. First, there must be significant support from management and administrative branches of the institutions looking to make the changes. Second, the future team members must be prepared to work together and embrace the shifting dynamic for the team to succeed. Team members might require training to become successful leaders or team members and how to work with others in a more collaborative setting. Ideally, the team leader will have had substantial leadership training and be prepared to employee transformational leadership strategies. Third, there must be sufficient resources (financial, infrastructure, personnel, etc.) to support the changes that are needed. As seen in the Aligning Forces for Quality study, hospitals who do not have sufficient resources, staff buy-in, or support from senior staff in the healthcare organization will not be able to make the necessary changes. Finally, sufficient tools and technology must be in place to support the emerging team science; long distance collaboration or even localized communication within a single organization or location must be optimized for teams to succeed.

Conclusions After reviewing the Cleveland Clinic case study and the Aligning Forces of Quality initiative, it is evident that team science and transformational leadership can be effective tools in healthcare settings. Well implemented interdisciplinary teams can result in improved communication and collaboration between many levels of the healthcare system (among providers, patients, administration, community partners, etc.), improved patient and hospital outcomes, and enhanced sharing of resources among large, geographically dispersed organizations. While team science and transformational leadership can generate remarkable results in the field of healthcare, they must also be accompanied by senior-level leadership support from within the organization, buy-in from other staff, and sufficient financial resources to support restructuring and training to ensure success.

Leadership in Healthcare and Public Health Copyright © 2018 by Elizabeth Hustead is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

• Open access
• Published: 01 December 2016

Transformational leadership, empowerment, and job satisfaction: the mediating role of employee empowerment

• Sang Long Choi 1 ,
• Chin Fei Goh 2 ,
• Muhammad Badrull Hisyam Adam 3 &
• Owee Kowang Tan 2  

Human Resources for Health volume  14 , Article number:  73 ( 2016 ) Cite this article

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Recent studies have revealed that nursing staff turnover remains a major problem in emerging economies. In particular, nursing staff turnover in Malaysia remains high due to a lack of job satisfaction. Despite a shortage of healthcare staff, the Malaysian government plans to create 181 000 new healthcare jobs by 2020 through the Economic Transformation Programme (ETP). This study investigated the causal relationships among perceived transformational leadership, empowerment, and job satisfaction among nurses and medical assistants in two selected large private and public hospitals in Malaysia. This study also explored the mediating effect of empowerment between transformational leadership and job satisfaction.

This study used a survey to collect data from 200 nursing staff, i.e., nurses and medical assistants, employed by a large private hospital and a public hospital in Malaysia. Respondents were asked to answer 5-point Likert scale questions regarding transformational leadership, employee empowerment, and job satisfaction. Partial least squares-structural equation modeling (PLS-SEM) was used to analyze the measurement models and to estimate parameters in a path model. Statistical analysis was performed to examine whether empowerment mediated the relationship between transformational leadership and job satisfaction.

This analysis showed that empowerment mediated the effect of transformational leadership on the job satisfaction in nursing staff. Employee empowerment not only is indispensable for enhancing job satisfaction but also mediates the relationship between transformational leadership and job satisfaction among nursing staff.

Conclusions

The results of this research contribute to the literature on job satisfaction in healthcare industries by enhancing the understanding of the influences of empowerment and transformational leadership on job satisfaction among nursing staff. This study offers important policy insight for healthcare managers who seek to increase job satisfaction among their nursing staff.

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In September 2010, the Economic Transformation Programme (ETP) was launched by the Malaysian government as part of the National Transformation Programme to achieve a self-sufficient, developed nation by 2020 [ 1 ]. The ETP was established to develop 12 National Key Economic Areas (NKEAs) to elevate gross national income per capita to US$15 000. Healthcare is one of the 12 NKEAs covered by the ETP. Changing demographics, an aging population, increasingly health-conscious lifestyles, and an affluent society have strengthened the rapidly growing healthcare sector in Malaysia [ 1 ]. The Malaysian government plans to create 181 000 new healthcare jobs by 2020 through the ETP [ 2 ].

In general, the Ministry of Health Malaysia has overall responsibilities to formulate policies for human resources regarding health [ 3 ]. The Ministry of Health acknowledges that it is of upmost importance to address human capital development in the Malaysian healthcare sector [ 3 , 4 ]. An adequate and competent workforce is vital to improving the delivery of healthcare services by reducing the probability of medical errors and improving service quality, among other benefits. In this regard, the shortage of human resources is the main problem experienced by the healthcare sector in Malaysia [ 5 , 6 ]. Specifically, the shortage of healthcare professionals who can provide skilled nursing services is a major challenge. In this study, we regard registered nurses and medical assistants as nursing staff [ 5 ]. In Malaysia, medical assistants are similar to nurse practitioners in other countries [ 7 ]. In addition to nursing services, medical assistants are also qualified to handle patients with simple acute conditions [ 8 ]. Nurses and medical assistants are required by law to undertake a different education program. Additionally, medical assistants and nurses are required to register under the respective statutory board before being eligible to practice. Owing to historical and cultural reasons, only females were eligible to become registered nurses, whereas males were only permitted to register as medical assistants until early 2000 [ 3 , 5 ]. The first batch of male nurses and female medical assistants were registered under their corresponding boards in the years 2008 and 2009, respectively [ 3 ]. However, nurses and medical assistants who intend to specialize in various specialties are assessed through credentialing in four areas: (1) intensive care, (2) perioperative care, (3) ophthalmology, and (4) emergency medicine and trauma care.

Similar to other Islamic nations, nursing staff in Malaysia are dominated by women and have a lower status compared to their Western counterparts [ 9 ]. The current nursing and health system in Malaysia is still largely the same as with the old system that was introduced during the British colonial era [ 9 ]. A study in Malaysia has shown that the majority of nurses can be described as ignorant of their oppressed status, exhibiting “unquestioning acceptance of the role of nurses, the power of the system, and the dominance of physicians” [ 9 ]. Multiple traditional and cultural factors have adversely influenced the status of nursing in Malaysia [ 9 , 10 ]. Among the primary reasons for the indigent status of nurses are the lack of public recognition, low educational entry requirements, and unfavorable employment conditions, including low salaries and poor working conditions. Such oppression adversely affects the job satisfaction of nursing staff in Malaysia [ 4 , 9 , 11 ]. Furthermore, nurses are often victimized as the root cause of declining nursing services in Malaysia while some important organizational factors, such as nursing shortage, lack of support, and poor working conditions, are overlooked [ 5 ]. The nursing shortage is evident from the 2010 report from the Malaysian Ministry of Health, which stated that the density of local nurses is 1.35 per 1000 people, which is 47.3% lower than the global density of nurses. Several reports have consistently noted that the high turnover of nurses is due to low job satisfaction in Malaysia [ 4 , 12 , 13 ]. Although no study to date has measured job satisfaction among medical assistants in Malaysia, we believe that they have low job satisfaction because of their job responsibilities in the nursing services. Therefore, job satisfaction among nursing staff is a main challenge for the Malaysian government in order to reform the healthcare sector through the ETP.

Traditional hierarchical structures in hospitals have resulted in medical dominance and suppressed nursing and other health professional in clinical environments [ 9 ]. Such problems are a major challenge in Islamic nations, including Malaysia. Recently, several scholars have suggested that a new form of healthcare leadership and empowerment is required to improve the job satisfaction of nursing staff in Malaysia [ 9 , 11 , 14 ]. The transactional style of leadership that pervades the healthcare institutions is believed to be a root cause of the nursing staff turnover rate [ 14 ]. Thus, transformational leadership can be adopted to complement the existing transactional leadership in healthcare institutions. Our review also shows that nursing management studies have offered preliminary evidence to support the aforementioned suggestions in the Malaysian context. First, several studies have found that transformational leadership is positively correlated with job satisfaction among nurses in Malaysia [ 15 , 16 ]. Second, prior studies have shown that empowerment is positively related to job satisfaction among nurses in Malaysia and in several other countries [ 11 , 17 , 18 ]. Furthermore, qualitative analysis has shown that empowerment could be a promising solution to restructuring the work environment and to reduce the powerlessness senses among nursing staff in Malaysia [ 9 , 11 , 12 ]. Nevertheless, this empirical evidence is fragmented, owing to a lack of comprehensive studies that investigate transformational leadership, empowerment, and job satisfaction among nursing staff in Malaysia.

Therefore, this research is focused on nursing staff, i.e., medical assistants and nurses, in the selected large private and public hospitals in Malaysia and explores the relationship among transformational leadership, empowerment, and job satisfaction. The purposes of this study were to (1) examine the influence of transformational leadership on job satisfaction, (2) investigate the influence of transformational leadership on empowerment, (3) investigate the influence of empowerment on job satisfaction, and (4) explore the mediating effect of empowerment between transformational leadership and job satisfaction. The mediating analysis is useful in predicting how the causal effect of transformational leadership on job satisfaction is intervened by employee empowerment and thus has tangible policy implications [ 19 ].

The study is based on a standardized survey to identify perceived transformational leadership traits, empowerment, and job satisfaction among nursing staff in the two studied hospitals. Purposive sampling was used and 200 valid samples were obtained. We sought to offer new evidence to highlight the importance of transformational leadership and empowerment in human resource development in the nursing profession in Malaysia. Specifically, transformational leadership has the potential to become a key strategic consideration for the ETP to build and retain qualified and skilled nurses in the healthcare industry.

• Transformational leadership

Transformational leadership was first conceptualized by Burns [ 20 ] and was then further developed by Bass [ 21 ]. In the current literature, the term tends to refer to Bass’ transformational leadership theory. According to Bass [ 22 ], there are four characteristics of transformational leaders. The first characteristic, individualized consideration suggests that transformational leaders support the development of subordinates’ skills and assist subordinates in achieving desired outcomes. Such leaders not only offer coaching and advices but also give employees attention and treat them as individuals. Second, transformational leadership includes intellectual stimulation, whereby leaders promote a culture in which employees will develop intelligence and rational thinking. Intellectual stimulation, in turn, fosters independent problem solving by employees. Inspiration is the third element of transformational leadership. In this regard, leaders communicate high expectations and encourage employees to focus their efforts on achieving established goals. To do this, transformational leaders tend to use effective communication techniques, such as symbols and simple language, to ensure that employees understand the main purposes of the assigned tasks. Finally, transformational leaders are regarded as charismatic leaders who offer a vision and a mission to employees. Such leaders will try to instill pride and gain respect and trust from employees so that the organization can achieve the required outcomes.

Many leadership scholars have agreed that transformational leadership plays a significant role in enhancing employee performance, trust, and commitment in organizations with a hierarchical authority structure [ 23 – 25 ]. The reason for this significance is that transformational leadership can be understood as a process of creating a vision and delivering a sense of belonging to employees [ 26 ]. Transformational leadership causes employees to perceive that the organization supports them and leads to attachments among the organization’s members. Such leadership establishes a strong relationship between employees and the organization, which supports organizational purposes. In short, transformational leadership builds a mission-oriented culture within an organization through a social influence process among organizational members [ 27 , 28 ].

• Job satisfaction

Job satisfaction can be manifested as employee commitment that results from an increased sense of meaningfulness at work and improved accomplishments [ 29 , 30 ]. Job satisfaction reflects employee perceptions of job performance. Employees with high levels of job satisfaction will feel that they are contributing positive value and outcomes to the organization. They also feel that they have a clear understanding of their job contribution. In addition, satisfied employees tend to perceive that they are treated fairly both inside and outside of an organization. In short, employees’ positive perceptions of their jobs and their organization can be revealed through job satisfaction.

Job satisfaction is a valuable indicator that management can use to assess overall employee development within an organization. Most satisfied employees tend to have very high self-confidence, which boosts their performance [ 31 , 32 ]. Job satisfaction is linked to the employees’ willingness to develop work skills and personalities because they can sense whether the organization is concerned about their well-being. Job satisfaction cannot be ignored if improving job performance is a priority for management. Individual personalities are often unique, and thus, employees’ expectations regarding their jobs differ across individuals. Individual consideration is therefore important for motivating employees to achieve better job performance. Likewise, Luthans [ 32 ] suggests that job satisfaction is closely related to employees’ positive emotional state. The perceived state is often a result of whether employees sense that they will gain in terms of personal development through a job experience. A study by Stup [ 33 ] also suggests that employees who perceive that they are treated fairly by leaders tend to value the organizational structure. As a result, employees will have stronger trust in and attachment to the organization, as well as show higher job satisfaction.

• Empowerment

Employee empowerment has been a topic of discussion for many years. Several scholars have cautioned that empowerment that may alter the power distribution structure in an organization is a double-edged sword [ 34 , 35 ]. To a certain extent, employee empowerment may be counterproductive to an organization. The rationale for this concern is that the implementation of empowerment practices signifies that a certain amount of authority and autonomy is given to employees. Some employees may become overconfident, and this false confidence will lead to management losing control over certain employees. These employees may abuse their power owing to misjudgments in their work. A good example of the potential downside of empowerment practices is when employees do not abide by corporate information management procedures when they are given access to confidential information [ 36 , 37 ], i.e., reduced monitoring and supervision increase the possibility that information will be leaked to outsiders.

As stated above, management may lose control of employees if empowerment is not properly executed. However, scholars generally acknowledge that employee empowerment enhances job performance (e.g., [ 38 , 39 ]). Empowerment is a strategic management option that can encourage employees to work beyond the norm and accomplish jobs in a flexible manner [ 38 ]. Such job flexibility is a precondition to instilling the decision-making ability of employees to respond swiftly to satisfy customer demands. More importantly, empowerment can stimulate employees’ attachment to their jobs because employees perceive the grant of decision-making authority as in indication that the organization appreciates their job contributions [ 39 ]. In short, job attachment is formed when employees associate positive emotions and acceptance with the organization.

Relationship between transformational leadership and job satisfaction

Transformational leaders are generally described as leaders who transform the values, desires, aspirations, and priorities of their employees and motivate employees to outperform expectations [ 40 ]. The link between transformational leadership and job satisfaction is well established in the current literature [ 41 ]. The characteristics of transformational leadership conceptualized by Bass [ 22 ] provide theoretical foundation for explaining employees’ job satisfaction.

Bogler [ 42 ] explains that transformational behaviors can affect job satisfaction through employees’ perceptions of transformational leaders. Such leaders increase employees’ expectations and recognition of their work and enhance employees’ job satisfaction through transformational leadership behaviors such as individual attention, intellectual stimulation, and motivation. Additionally, the participative decision-making style practiced by transformational leaders gives employees a sense of involvement. Thus, employees are more committed to their jobs and have higher levels of job satisfaction. In the same vein, the study by Nemanich and Keller [ 43 ] suggests that job satisfaction occurs when employees are valued through transformational leadership behaviors, namely individual consideration and inspiration. This relationship can be understood as a reciprocal exchange because employees gain job satisfaction and become committed to producing better job outcomes when they are valued by organizations.

Individual and team perceptions of transformational leadership are also positively related to job satisfaction [ 44 ]. Transformational leaders not only consider their followers individually but also recognize the importance of the team. This dual consideration is evidenced through transformational behaviors, such as motivation and inspiration, that are tailored to both the individual and the entire team. For example, transformational leaders will communicate a vision and demonstrate considerate behavior to encourage all team members to work together to achieve organizational goals. Furthermore, interpersonal conflicts can be reduced when individuals work together as a team; the job satisfaction of both individuals and the entire team will be strengthened.

The relevance of transformational leadership to employees’ job satisfaction is not restricted to a particular organizational setting. Prior studies have consistently found that transformational behaviors occur and enhance followers’ job satisfaction in various organizational settings, including educational, industrial, military, and volunteer settings [ 44 – 48 ]. For instance, Yang et al. [ 47 ] found that followers’ positive perceptions of transformational behaviors by leaders (or supervisors) lead to stronger identification with the organization, increased internalization of organizational goals, and improved job satisfaction.

As stated previously, the role of transformational leadership in enhancing employees’ organizational commitment and job satisfaction cannot be denied. The effect of transformational leadership is important for individuals who work in rapidly changing environments (for example, R&D personnel in technology-based organizations) to strengthen their organizational commitment and job satisfaction [ 45 ]. Indeed, transformational leadership is important to any organization that experiences environmental changes, including public sector organizations, which are commonly perceived as undergoing minimal organizational change. In a similar vein, a study by Wright and Pandey [ 25 ] suggests that transformational leadership behaviors are not limited by procedural constraints and rules in organizations with hierarchical authority structures. Such organizations can opt to change leadership styles even if their hierarchical decision-making structures may constrain transformational leadership behaviors.

In particular, scholars have acknowledged the importance of transformational leadership in enhancing the job satisfaction of staff in healthcare industries [ 49 – 53 ]. Employees in the healthcare sector often work in high-pressure environments. Supervisors’ transformational behaviors can establish a sense of self-control and competence among employees and thereby enhance job satisfaction [ 49 ]. Andrews and Dziegielewski [ 52 ] explain that nursing staff generally prefer supervisors with transformational behaviors that address employees’ individual needs. Thus, transformational leadership can reduce nursing staff turnover owing to low job satisfaction. This reasoning leads to the following hypothesis:

H1: Transformational leadership has a positive impact on job satisfaction among medical assistants and nurses in Malaysia.

Relationship between transformational leadership and empowerment

Empowerment is one of the mechanisms used to promote employee development in an organization’s long-term plan. Prior studies suggest that Bass’ [ 22 ] four characteristics of transformational leaders serve as antecedents to employee empowerment in organizations (e.g., [ 54 – 59 ]). Transformational leaders are persuasive and able to instill positive organizational perceptions among employees [ 60 ].

The charisma characteristic is considered to be a determinant of empowerment. Previous works suggest that charismatic leaders can intensify employee empowerment initiatives by offering vision and a sense of job ownership, as well as creating synergy and a climate of trust that fosters team spirit [ 54 , 60 – 62 ]. Additionally, charismatic leaders encourage employees to participate in the decision-making process, which will encourage employees to continuously develop skills and knowledge. Employees’ sense of responsibility is thus intensified. Employees will gain self-confidence and job-specific technical skills, and a sense of psychological identification is created. In sum, charismatic leaders use empowerment to foster employees’ sense of psychological identity with the organization.

Transformational leaders also use intellectual stimulation to empower employees. Sharing certain decision-making powers with employees is a precondition to promoting intellectual stimulation [ 55 , 56 ]. Employees who are granted decision-making power tend to repay the trust given to them by leaders by achieving organizational goals [ 63 ]. The delegation of power gives employees the sense that they are valued by the organization. Employees who value their leaders’ command will establish strong leader-employee relationships. A similar argument can be detected not only in the theoretical literature but also in empirical experiments. Prior studies have shown that transformational leadership has a positive impact on employee empowerment [ 24 , 54 , 55 , 61 ].

Individual consideration is equally important to encourage employees to accept an empowerment initiative [ 57 ]. Employees tend to be motivated when transformational leaders give them individual attention and build a coaching system to individually develop employees’ expertise. Such individual consideration can stimulate a productive working environment in an organization. Moreover, employees highly value their jobs when they are treated fairly and valued by leaders [ 60 ].

Notably, a recent study shows that transformational leaders tend to stimulate the acceptance of empowerment by employees [ 64 ]. All of the elements of transformational leadership conceptualized by Bass [ 22 ] are highly and positively correlated with empowerment success. In other words, these elements are valued as universal components of transformational behavior to empower employees in the workplace. The following hypothesis is thus proposed:

H2: Transformational leadership has a positive impact on employee empowerment among medical assistants and nurses in Malaysia.

Relationship between empowerment and job satisfaction

Employee empowerment is important for curbing workplace stress among employees [ 38 ]. The role of empowerment in enhancing job satisfaction is manifested by employees’ perceived job attachments and thus their reduced stress [ 39 ]. For example, when employees are given decision-making power, positive emotions and employee acceptance of the organization intensify. Empowered employees develop a climate of trust with their leaders and become more creative and innovative. Empowerment may foster critical thinking, which leads to employees working at a higher level. Such empowerment positively shapes employees’ perceptions of their jobs, reduces stress, and eventually leads to higher job satisfaction.

Those who work in healthcare industries largely view their working environment as stressful [ 49 ]. Work-related stress can lead to burnout and decreased job satisfaction. Empowerment can be viewed as an organizational initiative to give autonomy to employees for the purpose of diminishing feelings of powerlessness and removing formal barriers in the organizational environment [ 35 ]. It is believed that nursing staff must often respond to patient needs through rapid decision-making and thus the elimination of formal barriers is important. Organizations that embrace empowerment by sharing the decision-making process with their nursing staff will alleviate workplace-related stress [ 35 , 65 , 66 ]. This proposition leads to the next hypothesis:

H3: Employee empowerment has a positive impact on job satisfaction among medical assistants and nurses in Malaysia.

The conceptual framework has been constructed based on the hypotheses presented above regarding transformational leadership, empowerment, and job satisfaction (see Fig.  1 ). The framework indicates that empowerment is a mediator that exerts an intervening effect on the relationship between transformational leadership and job satisfaction.

Research framework

Study design and sample selection

The population of interest was selected by sampling during several stages. Table  1 presents statistics regarding hospitals and nurses in Malaysia. In 2014, there were 326 hospitals, 92 681 nurses, and 12 773 medical assistants in 13 Malaysian states. We initially selected the state of Johor because it is a prominent health tourism hub in Malaysia [ 67 , 68 ]. Johor is comprised of 10 districts, and we purposely selected Johor Bahru as the studied region. Johor Bahru is the second most populous state located in the southern part of Malaysia. Johor Bahru is known as the South Johor Economic Region and is a major corridor for economic development under the ETP [ 69 ]. There are three public and five private hospitals in Johor Bahru. A large private hospital and a large public hospital were chosen for this study. Both private and public hospitals are perceived as having stressful working conditions, but the nursing staff workload is heavier in public hospitals than in private hospitals, which is the result of the universal subsidization of public healthcare services in Malaysia [ 70 ].

The questionnaires were written in English. All questionnaires were administered face-to-face and were collected on site by one of the researchers within a 1-month period. During the data collection, the respondents were allowed to end the interview if they did not wish to answer certain questions. The researcher approached 350 nurses and medical assistants employed by the private and public hospitals selected for this study. However, 150 nurses and medical assistants either refused to answer the questionnaires or terminated their participation during the interview. For the latter case, we considered the incomplete surveys as invalid responses and that they were unwilling to participate in our study. In total, 101 and 99 valid responses (completed questionnaires) were obtained from the nursing staff of the public and private hospitals, respectively. The effective response rate was 57.14%.

This study was approved by the Commercialization & Technology Management Group (CTMG), a multidisciplinary research unit of the SmartDigital Community Research Alliance of Universiti Teknologi Malaysia, Malaysia. One of the researchers contacted the hospitals for permission to distribute the questionnaires. The names of the hospitals were not disclosed in accordance with the hospitals’ requests, and we believe that respondents prefer such information to be kept confidential. Furthermore, the questionnaires did not request the working position to be reported because it may reveal identifying information of medical assistants, as their proportion is significantly smaller than that of nurses. The respondents were aware of and willing to participate in this study. We assured the respondents of confidentiality before they completed the survey.

Survey instruments

A set of questionnaires was developed to measure the constructs in this conceptual model. The three constructs are transformational leadership (eight items), empowerment (five items), and job satisfaction (four items). Existing measurements for multi-item constructs that have been verified in the literature were used when possible. A 5-point Likert scale was used, ranging from 1 (strongly disagree) to 5 (strongly agree), to measure negative and positive assessments of the trait. Three survey instruments—transformational leadership, empowerment, and job satisfaction constructs—were used. The transformational leadership instrument was adapted from the Multifactor Leadership Questionnaire (MLQ) form developed by Bass and Avolio [ 71 ]. The transformational leadership instrument measures charisma, inspirational motivation, intellectual stimulation, and charisma exhibited by supervisors. The empowerment instrument was adapted from Matthews et al. [ 72 ], and the job satisfaction instrument was adapted from Warr et al. [ 73 ]. The empowerment instrument measures the perceived control of workplace decisions, the dynamic structural framework, and the fluidity in information sharing within the organization. The job satisfaction instrument measures the perceived compensation and the recognition dimensions among nursing staff. These instruments measure self-awareness of the nursing staff with respect to the transformational leadership, empowerment, and job satisfaction; thus, some discrepancies may exist if compared to external assessment.

All survey instruments were first reviewed by two experts to obtain feedback on their validity and clarity in the Malaysian context. The first expert, an academician whose research expertise is in human resource management, was asked to evaluate the content validity of the questionnaire. The second expert was a professional, a senior nurse, who evaluated the face validity of the questionnaire. The survey instruments were slightly modified based on feedback from the experts. The final questionnaire has four sections: the first section examines the demographic profiles of respondents; the second section investigates transformational leadership; the third section examines employee empowerment; and the final section investigates job satisfaction.

Statistical analysis

Data analysis was conducted using PASW Statistics 18.0 and SmartPLS 3.0. A descriptive analysis using PASW Statistics 18.0 was conducted to summarize the demographic backgrounds of the respondents. SmartPLS 3.0 was used to perform partial least squares-structural equation modeling (PLS-SEM) to validate the measurements and test the proposed hypotheses.

PLS-SEM is a second-generation regression technique for complex causal modeling, which is also known as variance-based structural equation modeling [ 74 – 77 ]. PLS-SEM is a causal modeling technique that is designed to maximize the explained variance of dependent variable(s). PLS-SEM is a preferred method when the research objective is prediction oriented. PLS-SEM also provides robust estimations of cause-and-effect-relationship models and/or when the collected data cannot meet certain assumptions (i.e., a small sample size and non-normal data). Compared to traditional regression techniques, PLS-SEM offers several significant advantages that suit our study [ 75 , 78 ]. First, PLS-SEM is a causal modeling technique that simultaneously estimates the dual roles of the mediator: one as a causal variable in the outcome and the other as an intervening variable in the mediation model. Second, PLS-SEM is appropriate for this exploratory study, which entails developing new ideas to verify the mediating role of empowerment between transformational leadership and job satisfaction. Third, PLS-SEM allows the testing of higher-order models, which contain two layers of constructs. In this study, job satisfaction is conceptualized as a two-dimensional construct (or higher-order model) that can be explained by recognition and pay . Modeling job satisfaction as a higher-order model reduces the number of relationships between transformational leadership and job satisfaction and between empowerment and job satisfaction. Otherwise, one would be required to estimate the relationship between transformational leadership and empowerment for each dimension of job satisfaction. The higher-order model approach allows the path model to be more parsimonious and easier to comprehend [ 75 ]. The reflective-reflective type of higher-order model was used to reflect the two dimensions of job satisfaction in this study. Following the suggestion of Hair et al. [ 75 ], a repeated indicator approach was used for the higher-order model (i.e., for job satisfaction).

Using the latest guidelines for PLS-SEM (e.g., [ 74 , 75 , 79 ]), we followed a two-step approach for assessing the measurement and structural models. In the first step, the assessment began with the measurement model. The assessment is to ensure sufficient construct reliability (i.e., indicator reliability and internal consistency) and validity (i.e., convergent validity and discriminant validity) are achieved. Additionally, Harman’s single-factor test was used to investigate common method bias. The reason for conducting this test is that self-report surveys were used to collect data regarding job satisfaction and thus the data may be susceptible to common method variance. The perceptual measures of explanatory and dependent variables were derived from the same respondents at the same time and respondents may have a propensity to offer consistent or systematic answers to survey questions that are otherwise not related [ 80 ].

The second step is to assess the structural models. In this regard, a PLS algorithm was selected based on considerations regarding our research design. Path weighting scheme was selected as the PLS algorithm because it can be applied to virtually all kinds of path model specifications and estimations, including a path model with a higher-order model [ 75 , 81 ]. A bootstrapping with 5000 samples was used to estimate the path coefficients’ significance in the path analysis [ 75 ]. A path analysis was performed for the structural model following the specific suggestion by Hair et al. [ 75 ] to perform the mediational analysis with PLS-SEM. Assessment was performed to ensure predictive relevance and the absence of multicollinearity in the structural models.

Descriptive statistics

Of the responses received, only 200 were found to be valid for analysis. Table  2 presents the demographics of the respondents in the two studied hospitals. Females represented 92.0% of the respondents, which is not surprising because nursing is a female-dominated profession in Malaysia [ 9 ]. The age group that was most represented in the survey was 26 to 30 years of age (59%). The largest educational background group was undergraduate diploma (95.5%). Approximately 60.5% of respondents indicated that they have 2–5 years of working experience. The findings in this study can be generalized to the two studied hospitals but are not representative of total populations of nurses and medical assistants in Malaysia. Thus, results should be interpreted with caution.

Measurement model

We assessed the construct reliability (i.e., indicator reliability and internal consistency) and validity (i.e., convergent validity and discriminant validity) for the measurement model (see Table  3 ). According to Hair et al. [ 74 ], the indicator loadings should be greater than 0.70, whereas loadings between 0.40 and 0.70 should be removed only if their deletion can increase the composite reliability to its minimum threshold value. Four indicator loadings ranged from 0.64 to 0.68, whereas all other indicator loadings were above 0.70. An analysis of the indicators with loadings less than 0.7 by deletion was conducted. Because the deletion of these indicators would not increase the respective composite reliability, the indicators were retained for this study. In short, the indicator loadings had satisfactory indicator reliability levels.

The assessment of the composite reliability showed that all constructs had a value greater than 0.7, which indicates sufficient internal consistency reliability [ 74 ]. An examination of the convergent validity and the discriminant validity was conducted to assess the validity of the constructs. First, the average variance extracted (AVE) of all constructs was greater than the minimum threshold value of 0.50, which verifies the convergent validity. Then, the study used the Fornell-Lacker criterion, which is a more conservative approach than cross-loadings, to assess discriminant validity [ 75 ]. The findings show that the discriminant validity is verified because the square root of the AVE of each construct is higher than its correlation with all other constructs (see Table  4 ).

It is important to note that the same evaluation criteria were utilized to evaluate the measurement model of the higher-order model (i.e., job satisfaction). As discussed above, the indicator loadings, composite reliability, and AVE for the higher-order construct of job satisfaction have satisfactory reliability and validity. In short, the measurement model assessment confirmed that all constructs, including the higher-order model, are reliable and valid.

Finally, Harman’s single-factor test was used to investigate common method bias. Four scaled constructs were loaded into a factor analysis. The results indicated that there are four factors present and that they account for 62.3% of the total explained variance. The highest load factor accounts for 37.4% of total variance explained. These results show that common method variance is not significant because no single factor emerges and no single factor accounts for the majority of the variances between measures [ 80 , 82 ].

Structural model

A step-by-step analysis was conducted to offer a thorough analysis. In the first step, the focus was on the relationship between transformational leadership and job satisfaction. Subsequently, the mediator (i.e., empowerment) was introduced, and the full structural model was assessed.

Figure  2 and Table  5 show the results of step 1 in the mediational analysis. First, an assessment of collinearity was performed to examine whether the predictor constructs were closely correlated with endogenous constructs. The (unreported) variance inflation factor (VIF) of the predictor constructs was below 3.0, indicating the absence of collinearity. Additionally, the Q 2 value generated by a blindfolding procedure was larger than zero, indicating the predictive relevance of the structural model [ 74 ]. The path analysis indicates that transformational leadership is positively related to job satisfaction ( p  < 0.01).

Structural model without the mediator

Next, the full structural model was assessed by including the empowerment construct (see Fig.  3 and Table  6 ). The Q 2 of the full structural model was above zero, and the (unreported) VIF was less than 3 for all predictor constructs. The results show that the positive effect of transformational leadership on job satisfaction remains significant ( p  < 0.05). Similarly, transformational leadership exhibits a positive effect on empowerment ( p  < 0.01), and empowerment, in turn, positively affects job satisfaction ( p  < 0.01).

Full structural model with the mediator

It is important to note that the relationship between transformational leadership and job satisfaction is significant in steps 1 and 2 but with a difference of 0.185. These results indicate that the mediator (i.e., empowerment) may absorb some effect of the relationship between transformational leadership and job satisfaction. Table  7 presents the mediating effect results, which show that the indirect effect is significant ( p  = 0.001, t value = 3.28). These results show that the variance accounted for (VAF) is 43.1%, which indicates that a partial mediating effect exists [ 75 ].

The Malaysian healthcare industry has experienced significant growth in recent years under the ETP, but human capital development in the healthcare sector remains a significant challenge. The purpose of this study is to investigate the causal relationships among perceived transformational leadership, empowerment, and job satisfaction amid nurses and medical assistants in the selected large private and public hospitals in Malaysia. This study also performed causal mediation analysis to identify the mediating effect of empowerment on the relationship between transformational leadership and job satisfaction.

First, we tested the hypothesis of whether transformational leadership has a positive impact on job satisfaction among medical assistants and nurses in two studied hospitals in Malaysia. The results show that transformational leadership positively affects job satisfaction and hypothesis H1 is accepted. Our results suggest that the perceived transformational leadership behaviors enhance job satisfaction among medical assistants and nurses. As such, our findings are consistent with correlation analyses from previous studies that investigated the relationship between transformational leadership and job satisfaction among nurses in Malaysia [ 15 , 16 ]. However, our findings offer the first empirical evidence to validate the causal impact of transformational leadership on job satisfaction among medical assistants and nurses in two studied hospitals in Malaysia.

The second hypothesis (H2) proposed that transformational leadership has a positive impact on employee empowerment among medical assistants and nurses in the two studied hospitals. The results indicate that the hypothesis is supported by the data. Our study presents empirical evidence that supports the shared view in workplace literature that transformational leadership can enhance employee empowerment within a hierarchical structure [ 15 , 24 , 45 , 46 , 54 , 55 , 83 , 84 ]. In this study, transformational leaders are those who exhibit charisma and have abilities to inspire and intellectually stimulate subordinates, not only individually but also as a team. Based on our findings, it appears that transformational leadership led to medical assistants and nurses to establishing a stronger sense of self-determination and competency, which could, in turn, significantly impact their work and job satisfaction.

The third hypothesis (H3) proposed that employee empowerment has a positive impact on job satisfaction among medical assistants and nurses in the studied hospitals. The results show that empowerment has a positive and significant influence on job satisfaction. The findings are consistent with several studies that found positive influence of empowerment on job satisfaction among nurses in Malaysia and other countries [ 11 , 17 , 18 ]. Such findings could be attributed to the role of employee empowerment in restructuring work environment that reducing the powerlessness senses among nursing staff in this study [ 9 , 11 , 12 , 17 , 18 ]. We believe that the empowerment effect may be more evident among Malaysian nursing staff where nursing is regarded as a low status and oppressed profession [ 9 ]. Thus, empowerment through mechanisms such as shared decision-making processes and improved autonomy can reduce the sense of powerlessness among nursing staff in an oppressive work environment. When nursing staff perceive that they are empowered, powerlessness and job burnout are mitigated, which results in higher job satisfaction.

The final step in the analysis was the examination of the causal mediation analysis to identify whether empowerment mediates the relationship between transformational leadership and job satisfaction among medical assistants and nurses in the studied hospitals. The results suggest that the indirect effect is significant, and partial mediating occurs, i.e., the employee empowerment explained the relationship between transformational leadership and job satisfaction.

Limitations and delimitations

The findings of this study should be interpreted with caution due to empirical design considerations. First, this study only investigates medical assistants and nurses from two hospitals in Malaysia, and thus, results are not representative of the entire Malaysian nursing workforce. Second, our sample size was not sufficient to disaggregate the analysis in order to identify the masking discrepancies between male and female nursing staff. Finally, this study uses a cross-sectional design, which makes it difficult to determine temporal relationships.

It is important to note that the response rate of the current study was 57.14%. The rate was caused by the distinctive sampling procedure in this study, i.e., potential respondents who were approached in this study were notified of their rights to refuse to participate or terminate the interview if they did not wish to answer certain questions. The majority of nursing staff who refused to participate in our study stated that they were busy whereas others did not give any reason. During the interview, the researchers would ask whether the nursing staff would like to terminate their participation if they seemed reluctant or uncomfortable to answer questions. Such approach was to ensure that they were treated with dignity and respect. Based on the observation during the data collection, there were no specific characteristics of nursing staff who refused to participate or terminated their participation during the interview. Similarly, there were no specific characteristics of those respondents who completed the interview. Nevertheless, it is impossible to completely rule out sampling bias that may be stemmed from distinctive sampling procedure in this study.

Theoretical and practical implications

This study has several theoretical implications. Theoretically, this study is the first in the nursing management literature to develop and verify a theoretical framework for the relationships between the perceptions of transformational leadership, empowerment, and job satisfaction. This study offers a more thorough understanding of what drives the level of job satisfaction among nursing staff. Prior studies have clearly indicated the direct positive effect of transformational leadership on employees’ job satisfaction in the healthcare industry [ 49 – 52 ] but lack a deeper understanding of the role of empowerment that underlies this relationship. The causal mediation analysis in this study confirms that empowerment mediates the relationship between transformational leadership and job satisfaction among medical assistants and nurses in two selected hospitals. In other words, employee empowerment cannot be detached when investigating transformational leadership and job satisfaction phenomena in nursing management. Second, this study developed and carried out field testing of an instrument for measuring three constructs, i.e., transformational leadership, empowerment, and job satisfaction, in nursing management literature. Third, this study achieved aforementioned theoretical contributions in nursing management literature in an understudied Malaysian context [ 5 , 12 ]. Finally, this study offers a baseline model for the role of transformational leadership in empowerment and job satisfaction in an institutional healthcare context. Because the oppression of nurses is a global phenomenon [ 9 , 85 ], we hope that our research may trigger an examination of the use of transformational leadership and empowerment as possible practices in human resources to enhance job satisfaction and increase the retention of nursing staff, especially in countries with similar institutional contexts, such as developing and Islamic countries.

This study also offers important insights for healthcare managers to implement policies to enhance job satisfaction among medical assistants and nurses. The implications of our study are aligned with the call from the World Health Organization to enable evidence-based policy-making for human resources for health in Malaysia [ 3 ]. First, job satisfaction can be altered if hospital administrators promote transformational leadership practices. However, raising transformational leadership practices are insufficient because employee empowerment will mediate the positive effect of transformational leadership on job satisfaction. From the perspective of the nursing staff, empowerment can be an indicator of organizational intent to give them autonomy by removing formal organizational barriers [ 35 ]. The ability of nursing staff to offer more rapid responses through decision-making will alleviate the work-related stress that causes job burnout and will thus contribute to higher job satisfaction. Furthermore, from a managerial perspective, employee empowerment can be an effective mechanism to promote employee development that is aligned with organizational goals. In short, transformational leadership and empowerment are the two essential ingredients that have tangible policy implications to address low job satisfaction among medical assistants and nurses especially in the two studied hospitals.

Finally, our empirical evidence can be a useful input for Malaysian policymakers to revamp human resources’ policies for healthcare under the ETP. The job satisfaction of healthcare workers ensures that the nursing profession will achieve its full potential, thereby safeguarding an effective health care delivery system [ 66 , 86 ]. In particular, our study highlights the important role of transformational leadership and empowerment in enhancing job satisfaction among medical assistants and nurses, which should be a focus of the Malaysian healthcare system under the ETP.

This study was designed to address a knowledge gap in nursing management research regarding the causal relationships among perceived transformational leadership, empowerment, and job satisfaction amid medical assistants and nurses in the selected hospitals in Malaysia. Additionally, causal mediation analysis was performed to examine whether empowerment mediates the relationship between transformational leadership and job satisfaction. The findings of this study suggest that transformational leadership positively influences job satisfaction among medical assistants and nurses in the studied hospitals. This study also shows that employee empowerment is indispensable for enhancing job satisfaction. Thus, the empowerment factor not only positively affects job satisfaction but also mediates the relationship between transformational leadership and job satisfaction. Overall, the findings suggest that policy intervention must cover both transformational leadership and empowerment to enhance job satisfaction among medical assistants and nurses.

The Performance Management and Delivery Unit. Overview of ETP, http://etp.pemandu.gov.my/About_ETP-@-Overview_of_ETP.aspx , Accessed 6 May 2016.

The Performance Management and Delivery Unit. ETP Annual Report 2014, http://etp.pemandu.gov.my/annualreport2014/ , Accessed 6 May 2016.

World Health Organization. Human Resources for Health Country Profiles—Malaysia. 2014.

Google Scholar  

Ministry of Health Malaysia. Country Health Plan (10th Malaysia Plan) 2011–2015, http://www.moh.gov.my/english.php/pages/view/196 , Accessed 1 May 2014.

Barnett T, Namasivayam P, Narudin DAA. A critical review of the nursing shortage in Malaysia. Int Nurs Rev. 2010;57(1):32–9.

Article   CAS   PubMed   Google Scholar  

Ministry of Health Malaysia. Health Facts, http://www.moh.gov.my/index.php/pages/view/58 , Accessed 1 Feb 2015.

Jaafar S, Noh KM, Muttalib KA, Othman NH, Healy J, authors: O, Maskon K, Abdullah AR, Zainuddin J, Bakar AA, et al. Malaysia Health System Review. Health Systems in Transition. 2012;3(1):1–102.

Khoo EM. The changing face of primary care: a cross sectional study in Malaysia. Sains Malaysiana. 2015;44(5):741–46.

Birks MJ, Chapman Y, Francis K. Women and nursing in Malaysia: unspoken status. J Transcult Nurs. 2009;20(1):116–23.

Article   PubMed   Google Scholar  

Bryant NH. Women in nursing in Islamic societies. Oxford: Oxford University Press; 2003.

Ahmad N, Oranye NO. Empowerment, job satisfaction and organizational commitment: a comparative analysis of nurses working in Malaysia and England. J Nurs Manag. 2010;18(5):582–91.

Lee SP, Chitpakdee B, Chontawan R. Factors predicting organizational commitment among nurses in state hospitals, Malaysia. Int Med J Malaysia. 2011;10(2):21–8.

Alam MM, Mohammad JF. Level of job satisfaction and intent to leave among Malaysian nurses. Business Intelligence J. 2010;3(1):123–37.

Thyer GL. Dare to be different: transformational leadership may hold the key to reducing the nursing shortage. J Nurs Manag. 2003;11(2):73–9.

Medley F, Larochelle DR. Transformational leadership and job satisfaction. Nurs Manag. 1995;26(9):64JJ–NN.

Article   CAS   Google Scholar  

Ahmad AR, Adi MNM, Noor HM, Rahman AGA, Yushuang T. The influence of leadership style on job satisfaction among nurses. Asian Soc Sci. 2013;9(9):172–8.

Article   Google Scholar  

Thorlakson AJH, Murray RP. An Empirical Study of Empowerment in the Workplace. Group Org Manag. 1996;21(1):67–83.

Yang J, Liu Y, Chen Y, Pan X. The effect of structural empowerment and organizational commitment on Chinese nurses’ job satisfaction. Appl Nurs Res. 2014;27(3):186–91.

Pearl J. Interpretation and identification of causal mediation. Psychol Methods. 2014;19(4):459.

Burns JM. Leadership. New York: Harper & Row; 1978.

Bass BM. Leadership and performance beyond expectations. New York: Free Press; 1985.

Bass BM. From transactional to transformational leadership: learning to share the vision. Organ Dyn. 1990;18(3):19–31.

Podsakoff PM, MacKenzie SB, Moorman RH, Fetter R. Transformational leader behaviors and their effects on followers’ trust in leader, satisfaction, and organizational citizenship behaviors. Leadersh Q. 1990;1(2):107–42.

Avolio BJ, Zhu W, Koh W, Bhatia P. Transformational leadership and organizational commitment: mediating role of psychological empowerment and moderating role of structural distance. J Organ Behav. 2004;25(8):951–68.

Wright BE, Pandey SK. Transformational leadership in the public sector: does structure matter? J Public Adm Res Theory. 2010;20(1):75–89.

Tse HH. Transformational leadership and turnover: the roles of LMX and organizational commitment. In Academy of Management Proceedings. Anaheim: Acad Manag; 2008. pp. 1–6.

Hofstede G. Cultural constraints in management theories. Executive. 1993;7(1):81–94.

Hofstede G. Culture’s consequences: comparing values, behaviors, institutions and organizations across nations. London: Sage Publications; 2001.

Kanter RM. Change masters: corporate entrepreneurs at work. Boston: International Thomson Business Press; 1983.

Locke EA. The nature and causes of job satisfaction. In: Dunnette MD, editor. Handbook of industrial and organizational psychology. Chicago: Rand McNally; 1976.

Bogler R, Somech A. Influence of teacher empowerment on teachers’ organizational commitment, professional commitment and organizational citizenship behavior in schools. Teach Teach Educ. 2004;20(3):277–89.

Luthans F. Organizational behavior. New York: McGraw-Hill; 2007.

Stup RE: Human resource management and dairy employee organizational commitment. In Journal of Dairy Science. Amer Dairy Science Assoc 1111 N Dunlap Ave, Savoy, IL 61874 USA; 2007: 329-329.

Appelbaum SH, Honeggar K. Empowerment: a contrasting overview of organizations in general and nursing in particular-an examination of organizational factors, managerial behaviors, job design, and structural power. Empower Organ. 1998;6(2):29–50.

Conger JA, Kanungo RN. The empowerment process: integrating theory and practice. Acad Manag Rev. 1988;13(3):471–82.

Cecez-Kecmanovic D, Janson M. The notion of lifeworld applied to information systems research. 2009.

Lawrence Öqvist K. The art of alchemy. Inf Secur Tech Rep. 2010;15(2):47–50.

Pearson LC, Moomaw W. The relationship between teacher autonomy and stress, work satisfaction, empowerment, and professionalism. Educ Res Q. 2005;29(1):38–54.

Zhang X, Bartol KM. Linking empowering leadership and employee creativity: the influence of psychological empowerment, intrinsic motivation, and creative process engagement. Acad Manag J. 2010;53(1):107–28.

Bass BM. Theory of transformational leadership redux. Leadersh Q. 1995;6(4):463–78.

Walumbwa FO, Wang P, Lawler JJ, Shi K. The role of collective efficacy in the relations between transformational leadership and work outcomes. J Occup Organ Psychol. 2004;77(4):515–30.

Bogler R. The influence of leadership style on teacher job satisfaction. Educ Adm Q. 2001;37(5):662–83.

Nemanich LA, Keller RT. Transformational leadership in an acquisition: a field study of employees. Leadersh Q. 2007;18(1):49–68.

Braun S, Peus C, Weisweiler S, Frey D. Transformational leadership, job satisfaction, and team performance: a multilevel mediation model of trust. Leadersh Q. 2013;24(1):270–83.

Griffith J. Relation of principal transformational leadership to school staff job satisfaction, staff turnover, and school performance. J Educ Adm. 2004;42(3):333–56.

Walumbwa FO, Orwa B, Wang P, Lawler JJ. Transformational leadership, organizational commitment, and job satisfaction: a comparative study of Kenyan and U.S. financial firms. Hum Resour Dev Q. 2005;16(2):235–56.

Yang F-H, Wu M, Chang C-C, Chien Y. Elucidating the relationships among transformational leadership, job satisfaction, commitment foci and commitment bases in the public sector. Public Personnel Manag. 2011;40(3):265–78.

Rowold J, Rohmann A. Transformational and transactional leadership styles, followers’ positive and negative emotions, and performance in German nonprofit orchestras. Nonprofit Manag Leadersh. 2009;20(1):41–59.

Nielsen K, Yarker J, Randall R, Munir F. The mediating effects of team and self-efficacy on the relationship between transformational leadership, and job satisfaction and psychological well-being in healthcare professionals: a cross-sectional questionnaire survey. Int J Nurs Stud. 2009;46(9):1236–44.

Wang X, Chontawan R, Nantsupawat R. Transformational leadership: effect on the job satisfaction of registered nurses in a hospital in China. J Adv Nurs. 2012;68(2):444–51.

Fuller JB, Morrison R, Jones L, Bridger D, Brown V. The effects of psychological empowerment on transformational leadership and job satisfaction. J Soc Psychol. 1999;139(3):389–91.

Andrews DR, Dziegielewski SF. The nurse manager: job satisfaction, the nursing shortage and retention. J Nurs Manag. 2005;13(4):286–95.

Luo Z, Fang P, Fang Z. What is the job satisfaction and active participation of medical staff in public hospital reform: a study in Hubei province of China. Hum Resour Health. 2015;13(1):34.

Article   PubMed   PubMed Central   Google Scholar  

Ashforth BE, Harrison SH, Corley KG. Identification in organizations: an examination of four fundamental questions. J Manag. 2008;34(3):325–74.

Vecchio RP, Justin JE, Pearce CL. Empowering leadership: an examination of mediating mechanisms within a hierarchical structure. Leadersh Q. 2010;21(3):530–42.

Men LR, Stacks DW. The impact of leadership styles and employee empowerment on perceived organizational reputation. J Commun Manag. 2013;17(2):171–92.

Jabnoun N, Juma AL, Rasasi A. Transformational leadership and service quality in UAE hospitals. Manag Serv Qual. 2005;15(1):70–81.

Sosik JJ, Cameron JC. Character and authentic transformational leadership behavior: expanding the ascetic self toward others. Consult Psychol J. 2010;62(4):251.

Mccann JAJ, Langford PH, Rawlings RM. Testing Behling and McFillen’s syncretical model of charismatic transformational leadership. Group Org Manag. 2006;31(2):237–63.

Epitropaki O, Martin R. The moderating role of individual differences in the relation between transformational/transactional leadership perceptions and organizational identification. Leadersh Q. 2005;16(4):569–89.

Wang G, Lee PD. Psychological empowerment and job satisfaction: an analysis of interactive effects. Group Org Manag. 2009;34(3):271–96.

Barroso Castro C, Villegas Periñan MM, Casillas Bueno JC. Transformational leadership and followers’ attitudes: the mediating role of psychological empowerment. Int J Hum Resour Manag. 2008;19(10):1842–63.

Ahearne M, Mathieu J, Rapp A. To empower or not to empower your sales force? An empirical examination of the influence of leadership empowerment behavior on customer satisfaction and performance. J Appl Psychol. 2005;90(5):945–55.

Givens RJ. The role of psychological empowerment and value congruence in mediating the impact of transformational leadership on follower commitment in American churches. Int J Leadersh Stud. 2011;6(2):188–214.

Okello DRO, Gilson L. Exploring the influence of trust relationships on motivation in the health sector: a systematic review. Hum Resour Health. 2015;13(1):1–18.

Taderera BH, Hendricks S, Pillay Y. Health personnel retention strategies in a peri-urban community: an exploratory study on Epworth, Zimbabwe. Hum Resour Health. 2016;14(1):1–14.

Ormond M, Mun WK, Khoon CC. Medical tourism in Malaysia: how can we better identify and manage its advantages and disadvantages? Global Health Action 2014, 7: 10.3402/gha.v3407.25201 .

Noor Hazilah Abd M, Husnayati H, Puteri Nemie Jahn K, Rokiah A, Zainurin D. Country perspective on medical tourism: the Malaysian experience. Leadersh Health Serv. 2015;28(1):43–56.

Rizzo A, Glasson J. Iskandar Malaysia. Cities. 2012;29(6):417–27.

Chee HL. Medical tourism and the state in Malaysia and Singapore. Global Social Policy. 2010;10(3):336–57.

Bass BM, Avolio BJ. MLQ: multifactor leadership questionnaire: technical report, leader form, rater and scoring key for MLQ (Form 5x-short). Redwood City: Mind Garden; 2000.

Matthews RA, Michelle Diaz W, Cole SG. The organizational empowerment scale. Pers Rev. 2003;32(3):297–318.

Warr P, Cook J, Wall T. Scales for the measurement of some work attitudes and aspects of psychological well-being. J Occup Psychol. 1979;52(2):129–48.

Hair JF, Ringle CM, Sarstedt M. PLS-SEM: indeed a silver bullet. J Mark Theory Pract. 2011;19(2):139–52.

Hair JF, Hult GTM, Ringle CM, Sarstedt M. A primer on partial least squares structural equation modeling (PLS-SEM). Thousand Oaks: Sage; 2013.

Henseler J, Dijkstra TK, Sarstedt M, Ringle CM, Diamantopoulos A, Straub DW, Ketchen DJ, Hair JF, Hult GTM, Calantone RJ. Common beliefs and reality about PLS: comments on Rönkkö and Evermann (2014). Organ Res Methods. 2014;17(2):182–209.

Wong KK-K. Partial least squares structural equation modeling (PLS-SEM) techniques using SmartPLS. Mark Bull. 2013;24(Technical Note 1):1–32.

Gunzler D, Chen T, Wu P, Zhang H. Introduction to mediation analysis with structural equation modeling. Shanghai Archives Psychiatry. 2013;25(6):390–4.

Chin WW: How to write up and report PLS analyses. In Handbook of Partial Least Squares. Edited by Esposito Vinzi V, Chin WW, Henseler J, Wang H. Heidelberg: Springer Berlin; 2010: 655-690: Springer Handbooks of Computational Statistics.

Chang S-J, Van Witteloostuijn A, Eden L. From the editors: common method variance in international business research. J Int Bus Stud. 2010;41(2):178–84.

Ringle CM, Wende S, Becker J-M. SmartPLS 3. Hamburg: SmartPLS; 2014.

Malhotra NK, Kim SS, Patil A. Common method variance in IS research: a comparison of alternative approaches and a reanalysis of past research. Manag Sci. 2006;52(12):1865–83.

Kark R, Shamir B, Chen G. The two faces of transformational leadership: empowerment and dependency. J Appl Psychol. 2003;88(2):246–55.

Top M, Tarcan M, Tekingündüz S, Hikmet N. An analysis of relationships among transformational leadership, job satisfaction, organizational commitment and organizational trust in two Turkish hospitals. Int J Health Plann Manag. 2013;28(3):e217–41.

McGibbon E, Mulaudzi FM, Didham P, Barton S, Sochan A. Toward decolonizing nursing: the colonization of nursing and strategies for increasing the counter-narrative. Nurs Inq. 2014;21(3):179–91.

Hotchkiss DR, Banteyerga H, Tharaney M. Job satisfaction and motivation among public sector health workers: evidence from Ethiopia. Hum Resour Health. 2015;13(1):1–12.

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Acknowledgements

We acknowledge with heartfelt thanks the reviewers and editor for their insightful comments and suggestions. We are also thankful to the respondents for their participation in this research.

Funding for this project was received from the Malaysian Ministry of Higher Education and Universiti Teknologi Malaysia under the research grant (Vot. 4F709). The research grant was used for supporting study design, analysis, and interpretation of data and in writing the manuscript.

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The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request.

Authors’ contributions

SLC carried out the main conception design, questionnaires, and analysis of data and drafted the manuscript revised final manuscript draft based on reviewer comments. CFG contributed to the improvement of conception design, performed the PLS-SEM analysis, revised the final manuscript draft based on reviewer comments, and finalizes and approves the final version of the manuscript. MBHA carried out the acquisition of data, questionnaires, and measures design. OKT carried out the planning of data collection and interpretation of data and revised the initial manuscript and final manuscript based on reviewer comments. All authors read and approved the final manuscript.

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Choi, S.L., Goh, C.F., Adam, M.B.H. et al. Transformational leadership, empowerment, and job satisfaction: the mediating role of employee empowerment. Hum Resour Health 14 , 73 (2016). https://doi.org/10.1186/s12960-016-0171-2

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Received : 19 November 2015

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DOI : https://doi.org/10.1186/s12960-016-0171-2

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