In the modern healthcare landscape where value-driven performance is a key to reimbursement, 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 outcomes.1 Nurse managers have a pivotal role in creating 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 employees for mutual goals is associated with better patient outcomes, fewer medical errors, and reduced staff turnover.2
Ensuring that nurse managers have the proper training and exposure to the concept of transformational leadership is crucial to organizational success. Unit-by-unit patient satisfaction scores were examined to determine whether improvement occurred after the implementation of a transformational leadership course. Each participating nurse manager evaluated his or her individual leadership style for transactional and transformational 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 organizations and regulatory agencies. Nurse managers must meet or exceed these performance measures (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 accomplished through transformational leadership.4
Why's patient satisfaction important? In addition to the obvious reason that patients want to receive quality care and be satisfied with their care, there's the fact that the hospital's reputation 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 recognized tool for assessing patient satisfaction during 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 preexisting data are the basis of the value-based purchasing, or pay-for-performance, model used by the CMS to reimburse for care provided. In fact, 30% of hospitals' reimbursements are tied to the patient experience as reported to the CMS.5 HCAHPS scores are also important because the results are publically reported; 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 databases were searched for the years 2009 to 2015: CINAHL, 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 this project, and each added insight in various ways.
The search yielded two systematic reviews that referenced a combined 28 studies, 5 cross-sectional correlational studies, 1 ethnography study, 1 mixed method study, and 1 informative peer-reviewed journal article. The selected studies took place in five different countries: the United States, Canada, Australia, Fiji, and Scotland. Most examined clinical nurses and their managers in acute care settings. The most frequent sampling methods were convenience and random. The dependent variables included patient safety, various patient outcomes, patient satisfaction, nurse performance, and organizational performance. The independent variables included leadership behaviors, violence perception, and leadership styles.
The literature review revealed that research tying patient satisfaction to leadership styles is a rich area for additional information, justifying this project. Areas for further research, as noted in several of the studies contained in the literature review, are correlating specific leadership styles with specific patient outcomes and expanding sample sizes and settings. By exploring the effects of leadership styles in a small community hospital, additional evidence on this subject was collected. This research specifically addressed the effect of leadership styles on patient outcomes; whereas, previous research found in the literature review is more general.
This study included two phases. Phase I involved the participants completing the Multifactor Leadership Questionnaire (MLQ) to evaluate their leadership style and obtaining patient satisfaction scores internally from Press Ganey data, which generate HCAHPS scores, for the corresponding time period. The MLQ survey has been used for over 25 years for research in military, government, educational, volunteer, and hospital organizations. A series of 45 questions were answered using a five-point Likert scale to identify a leader as “more transformational” or “less transactional.”7 The participants then participated in a 2-hour transformational leadership course.
Approximately 6 weeks after course completion, the participants entered Phase II. At this time, they repeated the MLQ survey and patient satisfaction scores were again obtained via the same method for the corresponding time period. The five nurse manager participants were from the following units: ICU, ED, medical-surgical, family birth, and perioperative services.
A simple linear regression analysis 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 patient satisfaction scores before the nurse managers took the transformational leadership course. Phase II represented patient satisfaction scores after they took the course.
In Phase I, the predictor wasn't significantly related to patient satisfaction scores [F(1,3) = 0.164, p = 0.713], so there wasn't enough evidence to reject the null hypothesis. Figure 1 illustrates the plot of the observed cases in relation to the expected regression line and it indicates 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 patient 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 reject the null hypothesis. Figure 2 illustrates the plot of the observed cases in relation to the expected regression line and indicates the overall fit of the model for Phase II data. In Phase II, it appears that there's a moderate positive linear relationship between the overall patient satisfaction score and the transformational leadership score after the nurse managers took the course.
A paired samples t-test was conducted to compare overall patient satisfaction scores before the nurse managers took the transformational leadership course (Phase I data) and after they took the course (Phase II data). Due to the small sample size, the data imply that there wasn't a statistically significant difference in overall 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 explained variance than the regression analysis for Phase I data. It should also be noted that the models only accounted for 5% and 33% of variance of the overall patient satisfaction scores, respectively. For this reason, researchers are encouraged to undertake similar studies to investigate other factors impacting overall patient satisfaction in relation to transformational leadership.
Expanding this study with an increased 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, physician services, interactions with other departments, organizational culture, and others. Future studies 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, including patient satisfaction scores, is one of the highest priorities for nurse managers. They must possess the leadership qualities necessary to achieve outcome goals set by their organization and standard benchmarks. Transformational leadership is an effective leadership style to successfully meet these goals. Nurse leaders who practice transactional leadership are unlikely to be as successful as those who practice transformational 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 question “Do nurse managers in a community hospital who apply a transformational leadership style have units with better patient satisfaction scores?” is yes. Although the data analysis results weren't statistically significant, there was a stronger linear correlation and explained variance in the Phase II 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 transformational 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 transforming clinical nurses to improve their practice and patient care techniques. Specifically, organizations should offer opportunities to assess leadership style, including the degree to which a manager practices transformational leadership; provide transformational leadership education courses; and promote a culture of transformational 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 preliminary support for the importance of transformational leadership practices. 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 speaking, the studies contained within the literature review and the results of this project are in agreement that there's a relationship between leadership styles and patient outcomes.
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