Performance Potential
Transforming leadership for
patient satisfaction
By Sheri Leonard McRae, DNP, RN, CPHQ, NEA-BC
I
n the modern healthcare landscape where
value-driven performance is a key to reim-
bursement, hospitals must make the most of
every opportunity to obtain high scores on
performance measures. Multiple studies show a
link between work environment and patient out-
comes.1 Nurse managers have a pivotal role in cre-
ating a positive work environment on the nursing
unit. The Institute of Medicine’s Future of Nursing
report advocates for leaders to collaborate with
others as mutually respected partners, indicating
that a leadership style which partners with em-
ployees for mutual goals is associated with better
patient outcomes, fewer medical errors, and re-
duced staff turnover.2
Ensuring that nurse managers have the proper
training and exposure to the concept of transfor-
mational leadership is crucial to organizational
success. Unit-by-unit patient satisfaction scores
were examined to determine whether improve-
ment occurred after the implementation of a trans-
formational leadership course. Each participating
nurse manager evaluated his or her individual
leadership style for transactional and transforma-
tional characteristics. (See Table 1.)
A look at the significance
Nurse managers are often inadequately prepared
for leadership roles.3 Nonetheless, they’re required
to lead a team of nurses—sometimes in excess of
100 employees—to meet various goals set by orga-
nizations and regulatory agencies. Nurse manag-
ers must meet or exceed these performance mea-
sures (employee retention rates, quality and safety
measures, and patient satisfaction scores), all of
which have an impact on unit and organizational
financial viability. Creating a culture conducive to
positive patient outcomes is an essential skill for
frontline nurse managers. This can be accom-
plished through transformational leadership.4
Why’s patient satisfaction important? In addi-
tion to the obvious reason that patients want to
receive quality care and be satisfied with their
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care, there’s the fact that the hospital’s reputa-
tion and financial state are constantly at risk.
Since its creation in 2002, the Hospital Consumer
Assessment of Healthcare Providers and Systems
(hcahps) survey has been a nationally recog-
nized tool for assessing patient satisfaction dur-
ing an acute care stay. When the Affordable Care
Act was signed into law in March 2013, hcahps
results became vitally significant for all hospitals
participating with the Centers for Medicare and
Medicaid Services (CMS). Surveys that use pre-
existing data are the basis of the value-based
purchasing,
or pay-for-
performance,
model used by
the CMS to re-
imburse for
care provided.
In fact, 30% of
hospitals’ re-
imbursements
are tied to the
patient experi-
ence as re-
ported to the
CMS.5 hcahps
scores are also
important because the results are publically re-
ported; healthcare consumers can research acute
care hospitals and make facility selections based
on these easily accessible data.6
Reviewing the evidence
A systematic literature review was conducted to
explore current evidence correlating effective unit
leadership with selected performance measures
and patient outcomes. The following online data-
bases were searched for the years 2009 to 2015: CI-
NAHL, Cochrane, PubMed, and PsychINFO. The
terms “leadership” and “patient outcomes” were
searched in each database for a total of 429 titles.
Ten studies were identified as being pertinent to
Nursing Management • February 2017 51
 Performance Potential

this project, and each added insight

in various ways. Table 1: Transactional vs. transformational leadership styles8
The search yielded two system-
Transactional leaders Transformational leaders
atic reviews that referenced a com-
bined 28 studies, 5 cross-sectional Approach staff members with an eye to Raise staff members’ awareness of the
correlational studies, 1 ethnogra- exchanging one thing for another importance of achieving valued outcomes
and the strategies for reaching them
phy study, 1 mixed method study,
and 1 informative peer-reviewed Recognize what staff members want to get Encourage staff members to transcend
journal article. The selected studies from their work and try to see that they get it, their self-interest for the sake of the team,
if their performance warrants organization, or larger policy
took place in five different coun-
tries: the United States, Canada, Exchange rewards and promises of reward for Develop staff members’ levels of
Australia, Fiji, and Scotland. Most appropriate levels of effort achievement, autonomy, and affiliation
examined clinical nurses and their Respond to the staff members’ needs and Inspire staff members to perform beyond
managers in acute care settings. desires as long as they’re getting the job done standard expectations
The most frequent sampling meth-
ods were convenience and random.
The dependent variables included justifying this project. Areas for leadership styles on patient out-
patient safety, various patient out- further research, as noted in several comes; whereas, previous research
comes, patient satisfaction, nurse of the studies contained in the liter- found in the literature review is
performance, and organizational ature review, are correlating spe- more general.
performance. The independent cific leadership styles with specific
variables included leadership be- patient outcomes and expanding The findings
haviors, violence perception, and sample sizes and settings. By ex- This study included two phases.
leadership styles. ploring the effects of leadership Phase I involved the participants
The literature review revealed styles in a small community hospi- completing the Multifactor Lead-
that research tying patient satisfac- tal, additional evidence on this ership Questionnaire (MLQ) to
tion to leadership styles is a rich subject was collected. This research evaluate their leadership style
area for additional information, specifically addressed the effect of and obtaining patient satisfaction
scores internally from Press Ganey
data, which generate hcahps
Figure 1: Plot of the overall patient satisfaction scores regression scores, for the corresponding time
line for Phase I period. The MLQ survey has been
used for over 25 years for research
Normal P-P plot of regression standardized residual
in military, government, educa-
Dependant variable: Overall patient satisfaction
tional, volunteer, and hospital
1.0
organizations. A series of 45
questions were answered using a
0.8
five-point Likert scale to identify
Expected cumulative probability

a leader as “more transforma-

tional” or “less transactional.”7
0.6 The participants then participated
in a 2-hour transformational lead-
ership course.
0.4 Approximately 6 weeks after
course completion, the partici-
pants entered Phase II. At this
0.2 time, they repeated the MLQ sur-
vey and patient satisfaction scores
were again obtained via the same
0.0 method for the corresponding
0.0 0.2 0.4 0.6 0.8 1.0 time period. The five nurse man-
Observed cumulative probability ager participants were from the

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 Performance Potential

A paired samples t-test was

Figure 2: Plot of the overall patient satisfaction scores regression conducted to compare overall pa-
line for Phase II tient satisfaction scores before the
Normal P-P plot of regression standardized residual nurse managers took the transfor-
Dependant variable: Overall patient satisfaction mational leadership course (Phase
1.0 I data) and after they took the
course (Phase II data). Due to the
small sample size, the data imply
0.8 that there wasn’t a statistically
Expected cumulative probability

significant difference in overall

0.6
0.4
0.2
0.0
0.0
following units: ICU, ED, medi-
cal-surgical, family birth, and
perioperative services.
A simple linear regression anal-
ysis was conducted to evaluate
the effect of the predictor variable
(transformational leadership style)
on the criterion variable (patient
satisfaction scores). The analysis
investigated two separate phases
of data. Phase I represented pa-
tient satisfaction scores before the
nurse managers took the transfor-
mational leadership course. Phase
II represented patient satisfaction
scores after they took the course.
In Phase I, the predictor wasn’t
significantly related to patient satis-
faction scores [F(1,3) = 0.164, p =
0.713], so there wasn’t enough evi-
dence to reject the null hypothesis.
Figure 1 illustrates the plot of the
observed cases in relation to the ex-
pected regression line and it indi-
cates the overall fit of the model for
Phase I data. In Phase I, it appears
that there’s a weak positive linear
relationship between the overall pa-
0.2 0.4 0.6 0.8 1.0
Observed cumulative probability
tient satisfaction score and the
transformational leadership score
before the nurse managers took the
course.
In Phase II, the predictor wasn’t
significantly related to the criterion
variable [F(1,3) = 0.145, p = 0.315],
so there wasn’t enough evidence to
Nurse leaders who practice transactional leadership are
unlikely to be as successful as those who practice
transformational leadership.
reject the null hypothesis. Figure 2
illustrates the plot of the observed
cases in relation to the expected re-
gression line and indicates the over-
all fit of the model for Phase II data.
In Phase II, it appears that there’s a
moderate positive linear relation-
ship between the overall patient
satisfaction score and the transfor-
mational leadership score after the
nurse managers took the course.
patient satisfaction scores before
and after the nurse managers took
the transformational leadership
course.
Although the analysis suggested
no significant difference in overall
patient satisfaction scores before
and after the course, it should be
noted that the regression analysis
for Phase II data yielded a slightly
stronger linear correlation and ex-
plained variance than the regres-
sion analysis for Phase I data. It
should also be noted that the mod-
els only accounted for 5% and 33%
of variance of the overall patient
satisfaction scores, respectively. For
this reason, researchers are encour-
aged to undertake similar studies to
investigate other factors impacting
overall patient satisfaction in rela-
tion to transformational leadership.
Expanding this study with an in-
creased sample size would most
likely yield statistically significant
results. Another limitation is the
set of possible extraneous variables
that affect patient satisfaction
scores, such as census, nursing
competence, environment, physi-
cian services, interactions with
other departments, organizational
culture, and others. Future studies

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

 Performance Potential
should include methodology to
identify these extraneous variables
and isolate them from the overall
results. The timeliness of posted
hcahps scores on the Hospital
Compare website is also a potential
problem. Lengthening the study’s
duration and allowing additional
time between the two phases
would be ideal. A possible third
phase could include a refresher
course or additional education on
transformational leadership.
A top priority
Improving patient outcomes, in-
cluding patient satisfaction scores,
is one of the highest priorities for
nurse managers. They must pos-
sess the leadership qualities neces-
sary to achieve outcome goals set
Organizations can benefit by promoting frontline managers’
use of transformational leadership.
by their organization and standard
benchmarks. Transformational
leadership is an effective leader-
ship style to successfully meet
these goals. Nurse leaders who
practice transactional leadership
are unlikely to be as successful as
those who practice transforma-
tional leadership; leaders who see
their staff members as partners and
gain their respect will experience
better patient outcomes than those
who merely direct and reward.
The answer to the research ques-
tion “Do nurse managers in a com-
munity hospital who apply a
transformational leadership style
have units with better patient sat-
isfaction scores?” is yes. Although
the data analysis results weren’t
statistically significant, there was a
stronger linear correlation and ex-
plained variance in the Phase II
54 February 2017 • Nursing Management
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
data, which were collected after
the nurse managers participated in
the transformational leadership
course. The results of this study,
combined with the literature cited,
indicate that patient outcomes can
be improved on units managed by
leaders who exhibit transforma-
tional characteristics.
Organizations can benefit by
promoting frontline managers’ use
of transformational leadership and
continually training nurse leaders
who exhibit behaviors conducive
to positively growing and trans-
forming clinical nurses to improve
their practice and patient care
techniques. Specifically, organiza-
tions should offer opportunities to
assess leadership style, including
the degree to which a manager
practices transformational leader-
ship; provide transformational
leadership education courses;
and promote a culture of transfor-
mational leadership practices
throughout the organization. If this
is accomplished, a “win-win-win-
win” situation is created: Nurse
managers lead effectively, clinical
nurses are satisfied and practice
safely, organizations achieve
maximum reimbursement for pay-
for-performance efforts, and—most
important—patient outcomes are
optimal.
This project provides prelimi-
nary support for the importance of
transformational leadership prac-
tices. The results are applicable to
multiple leadership positions
within nursing and healthcare, and
are important to any organization
with a strategic plan to improve
patient outcomes. Generally speak-
ing, the studies contained within
the literature review and the
results of this project are in
agreement that there’s a relation-
ship between leadership styles and
patient outcomes. NM
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Sheri Leonard McRae is an assistant profes-
sor of health sciences and program coordina-
tor of health administration at King University
in Bristol, Tenn.
The author has disclosed no financial relation-
ships related to this article.
DOI-10.1097/01.NUMA.0000511923.13387.69
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