Personal and organisational attributes that support transformational leadership in acute healthcare: scoping review

Rationale

Hospital-based health care is experiencing unprecedented challenges of severe workforce shortages and healthcare professional burnout, moral distress and mental health issues.¹² Transformational leadership has clear benefits for patients, staff and organisations^4–10 but the personal and organisational attributes that support transformational leadership in health care are less well understood. Transformational leadership will be critical to the immediate future of health care, the preservation of the current healthcare workforce, recruitment and retention of new healthcare professionals and to safety and quality of care as these challenges are traversed.

Aim

The aim of this scoping review was to explore the personal and organisational attributes that support transformational leadership in acute health care. The ‘Population, Concept and Context’ framework was used to guide question development.¹³ The population of interest was healthcare leaders, the concept was transformational leadership and the context was studies from acute care hospitals.

Eligibility criteria

Primary research studies, published in English, related to personal or organisational attributes supporting transformational leadership in acute health care were included. Studies of leadership styles other than transformational leadership, or conducted in settings other than acute health care (including but not limited to residential aged care, rehabilitation and community care) were excluded. Editorials, theses, letters, commentaries, opinion papers, case studies, case reports and conference abstracts were also excluded.

Information sources and search strategy

The following databases were searched on 18 August 2023: Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Medline Complete, PsycInfo and Emerald Insight. No restrictions were placed on date of publication and each database was searched from inception onwards. The search strategies for each database are shown in Supplementary material Appendix S1. Forward (searching for articles that cite included studies) and backward (search of reference lists of included studies) citation searching was also conducted.

Selection of sources of evidence

EndNote 20.0 was used to identify and remove duplicates. Covidence^®16 online software was used to store, organise and manage references. Two independent reviewers screened all articles at both the title/abstract and full text screening phases. Disagreements were resolved by consensus and discussion with members of the research team.

Data charting

Data were extracted by two authors (JD and NK) using a project specific data charting form and ratified by a third author (JC). The following data were charted for each included study: authors, year of study, country, study aim, design, setting, sample and major findings.

Synthesis of results

Given the anticipated variation in study design, settings, samples and outcomes, the approach to synthesis was guided by the SWiM reporting guidelines and narrative synthesis methods.¹⁵

Ethics

Ethics approval was not required for this scoping review.

Characteristics of sources of evidence

The included studies were from the United States of America (n = 7),^17–23 two studies each from Slovakia^24,25 and Brazil,^26,27 and single studies each from Australia,²⁸ Canada,²⁹ Germany,³⁰ Ghana,³¹ Jordan,³² Kuwait³³ and Turkey.³⁴ A total of 14 studies reported personal attributes supporting transformational leadership: 11 quantitative studies used surveys^{17,19,20,22,23,25,26,30–33} and 3 qualitative used interviews.^26–28 Eleven studies of personal attributes focused on nursing and included nurse managers (n = 5), ^{20,23,25,27,32} nurses with/without midwives (n = 3),^20,26,31 nurse leaders (not defined) (n = 2),^19,31 nurse executives (n = 2)^17,20 or chief nursing officers.²² Three studies were of healthcare leaders of different professions^28,30,33 and one study focused on hospital vice-presidents.¹⁷

Eight studies reported organisational attributes supporting transformational leadership: seven quantitative studies used surveys^{17,18,21,24,25,29,34} and one used qualitative interviews.²⁸ Seven studies of organisational attributes focused on nursing including nurse managers (n = 3)^25,29,34 nurses with/without midwives (n = 2),^29,34 nurse leaders (not defined),³¹ nurse administrators,²¹ nurse executives¹⁷ and nursing associate directors.²⁹ Two studies focused on healthcare managers (not defined)²⁴ or healthcare leaders of different professions.²⁸ In one study the unit of measurement was the hospital so one representative¹⁸ from each site was surveyed.

Results of individual sources of evidence

The personal attributes supporting transformational leadership reported in quantitative studies (Table 1) were most commonly manager educational preparation (n = 5),^{17,19,22,23,25} years of management experience (n = 4),^22,25,32,33 age (n = 3)^22,25,33 and emotional intelligence (n = 3).^23,31,32 Five studies reported positive association between higher levels of educational preparation and transformational leadership.^{17,19,22,23,25} The levels of education compared varied between studies: higher education degree versus not,¹⁷ secondary education versus university degrees,²⁵ doctoral versus master’s degrees,²² master’s versus bachelor’s degrees,²³ and comparison of diploma, associate degree, bachelor’s degree and master’s degree or higher.¹⁹

The relationship between transformation leadership and years of management experience was mixed. One study reported >15 years of management experience had positive association with transformational leadership,³² one study reported negative correlation between transformational leadership and years of management experience²⁵ and two studies failed to show a significant relationship between transformational leadership and years of management experience.^22,33 Two studies reported no significant relationship^22,33 and one study reported a significant negative correlation between transformational leadership and increasing manager age.²⁵ All three studies that examined emotional intelligence reported a positive association with transformational leadership.^23,31,32 In particular, managers’ self-emotion appraisal had a significant relationship with transformational leadership but managers’ self-perceived ability to recognise and understand other people’s emotions had no significant relationship with transformational leadership.³¹

One quantitative study reported manager inexperience and younger age as challenges to transformational leadership.²⁶ Other themes from the qualitative studies of personal attributes supporting transformational leadership were related to decision accountability, agility and risk navigation (hospital leaders),²⁸ leading by example and dialogical relationship (nurses),²⁶ and getting the best from the team, coordinating team work and development of leadership skills (emergency department and intensive care nurse managers).²⁷

The organisational attributes supporting transformational leadership reported in quantitative studies also varied (Table 2) and were most commonly larger organisational size (n = 2)^17,18 and culture (n = 2).^18,29 All studies of these attributes reported positive association with transformational leadership.^17,18,29 The single qualitative study of organisational attributes supporting transformational leadership reported organisational agency and communication acceleration and innovation as enablers of transformational leadership.²⁸

Synthesis of results

The research team categorised personal attributes as manager: (i) demographics,^22,25,31,33 (ii) role characteristics,^{19,22,25,32,33} (iii) leadership preparation^{17,19,22,23,25,30} and (iv) traits^{19,20,22,23,25,32,33} (Table 1). There was no significant relationship between transformational leadership and manager gender,^31,33 and the relationship between transformational leadership and manager age is presented above.^22,25,33 Manager role characteristics reported in four studies were years of management experience,^22,25,32,33 job title (clinical manager versus senior clinical manager versus nursing director)¹⁹ and span of control (number of persons directly managed by the manager).²⁵ The conflicting results between transformational leadership and management experience is presented above.^22,25,32,33 Higher job titles¹⁹ and lower span of control (fewer direct reports)²⁵ had significant positive associations with transformational leadership.

Manager leadership preparation was reported in six studies^{17,19,22,23,25,30} and included formal university-based educational preparation,^{17,19,22,23,25} leadership training³⁰ and management qualifications;^23,25 all had significant positive associations with transformational leadership. It should be noted that one of these studies showed a significant positive correlation between educational preparation and management qualifications,²⁵ and another study examined educational preparation and management qualifications separately without assessing for collinearity.²³

The manager traits reported in seven studies^{19,20,22,23,25,32,33} included emotional intelligence,^23,31,32 transactional leadership,²⁰ vigour,²² dedication²² and absorption.²² As highlighted above, there was significant positive relationship between emotional intelligence and transformational leadership.^23,31,32 One study reported a significant weak positive correlation between transformational and transactional leadership in both nurse executives and nurse managers.²⁰ One study reported that vigour (energy, resilience, willingness to invest effort and persistence in the face of difficulties), dedication (sense of significance, enthusiasm, pride, inspiration and challenge from one’s work) and absorption (totally and happily immersed in one’s work) had significant positive associations with specific elements of transformational leadership.²² The traits of vigour, dedication and absorption were examined separately without assessing for collinearity.²²

The research team categorised organisational attributes as: (i) manager support,^25,34 (ii) organisational characteristics^17,18,21,29 and (iii) organisational processes or systems^18,21,24 (Table 2). The manager supports of psychosocial work factors²⁵ and manager education and training³⁴ were reported in two studies. Psychosocial work factors (job demand, job control and managerial support) had a significant strong positive correlation with transformational leadership.²⁵ One study reported that a transformational leadership training program had significant positive impacts on charge nurses’ transformational leadership behaviours.³⁴

The organisational characteristics reported were organisational size,¹⁸ hospital structure²⁹ and organisational culture,^17,29 and all supported transformational leadership. In one study using hospitals as the unit of measurement, there was a significant weak positive correlation between transformational leadership scores and hospital size.¹⁸ One study reported significant associations between transformational leadership and hospital structure and culture, however, the measures of hospital structure and culture were unclear.²⁹ One study reported a significant positive correlation between nurse executives’ transformational leadership and working in a participative organisation versus those working in an authoritarian organisational climate.¹⁷

The organisational processes or systems reported were quality management,¹⁸ knowledge management,¹⁸ models of human resource management,²⁴ strategic planning²¹ and resource allocation.²¹ One study reported significant weak to moderate positive correlations between transformational leadership and quality management and various elements of organisational knowledge management (acquisition, dissemination and responsiveness). One study reported a significant strong positive relationship between transformational leadership and a mixed role human resources management department that fulfilled strategic partner, administrator, employee rights activist and change agent roles.²⁴ One study reported significant positive relationships between transformational leadership domain and strategic planning and resource allocation.²¹

Summary of evidence

Despite the beneficial outcomes of transformational leadership for patients, staff and organisations, personal and organisational attributes supporting transformational leadership are not well understood. There was variability in the personal attributes examined and many were examined in isolation with no consideration of relationships between variables, for example age, years of management experience and role seniority. There was no strong evidence that older leaders^22,25,33 or leaders with more years of management experience^22,25,32,33 had stronger transformational leadership behaviours. Other studies have also reported a lack of association between leadership experience and transformational leadership.^11,35 These results call into question that transformational leadership is a function of older or more experienced managers, and that transformational leaders need to be in senior positions, older or have greater years of management experience.

Our results showed managers’ emotional intelligence^23,31,32 and leadership preparation via education^{17,19,22,23,25,30} had positive relationships with transformational leadership. Significant relationships between emotional intelligence and transformational leadership are reported in both healthcare^11,35 and non-healthcare contexts.^36,37 The relationship between transformational leadership and emotional intelligence in health care is not surprising given that healthcare professionals practice in a relational and caring context; transformational leadership is grounded in motivating followers to achieve,³⁵ and emotional intelligence is the ability to understand and manage one’s own emotions and appreciate and influence the emotions of others.³⁸ The positive relationship between transformational leadership and educational preparation mirrors that of other studies.^39,40 Systematic reviews^11,39,40 have shown that educational interventions improve leadership behaviours, however, the difficulty in making definitive recommendations regarding best educational practice given the limited evidence base and high levels of variability in studies is also acknowledged.

There was also variability in the organisational attributes reported. Again, many organisational variables were examined in isolation when it may be argued that manager support,^25,34 organisational characteristics^17,18,21,29 and organisational processes or systems^18,21,24 may be inter-related. Larger organisational size^17,18 had a positive association with transformational leadership, but it is plausible that larger organisations have more managers and greater resources (including manager training, education and support) and better organisational processes, which also had a positive association with transformational leadership.^18,21,24 Organisational processes that support transformational leadership, particularly those focused on collective outcomes, are important mediators between leadership and organisational performance outcomes.⁴¹

Organisational culture,^18,29 participative organisations¹⁷ and specific factors such as organisational agency,²⁸ communication²⁸ and innovation²⁸ were enablers of transformational leadership. This is not surprising given transformational leadership is a values-based leadership style that places high importance on relationships and the success of others.^3,4 The work factors strongly related to transformational leadership in this review: job demand, job control and managerial support,²⁵ may also be linked to organisational culture. Job control and workplace support are important for employee wellbeing, including that of leaders. High levels of job control and workplace support are protective against emotional exhaustion and burnout,⁴² both of which result in adverse staff and patient outcomes.⁴³

Limitations

The strengths of this review are the thorough and systematic search technique, clear inclusion and exclusion criteria and comprehensive data extraction. The major limitation of this review was that studies were limited to publications in English. The significant heterogeneity across studies precluded meta-synthesis. Many of the included studies used self-reported data from surveys or interviews thus presenting methodological limitations of rating bias, common methods bias and confounding leadership behaviours with intended outcomes.⁴⁴ We argue that many variables that support transformational leadership may be inter-related so more sophisticated study designs are warranted. Finally, the a priori focus of this scoping review was the personal and organisational attributes that support transformational leadership in acute health care, therefore we did not explicitly explore the barriers to transformational leadership.