Linking Transformational Leadership to Patient Care Quality: The Role of Structural Empowerment and Registered Nurses’ Clinical Leadership

BACKGROUND: Effective leadership is critical in driving and motivating registered nurses to provide high-quality patient care. A link between effective transformational leadership (TL) in nursing and improved patient care outcomes has been established, but it is unknown how this association is affected. AIM: To examine the relationships between TL, structural empowerment (SE), registered nurses' clinical leadership (CLS) and patient care outcomes. METHODS: This quantitative cross-sectional study was conducted in a government tertiary hospital in Saudi Arabia, with 1038 registered nurses clustered under 28 head nurses. Instruments used included the Multifactor Leadership Questionnaire, Conditions of Work Effectiveness Questionnaire II, clinical leadership survey and self-reported measures of patient adverse events (AEs) and nursing care quality. Data were analysed using SPSS Version 28 and the R 4.3.3 packages 'lavaan', 'semPlot' and 'semTools' for multilevel structural equation modelling (MSEM). RESULTS: Six hundred and sixty-four surveys (response rate = 70%) were analysed. Multilevel analysis showed a significant positive association between TL and SE (β = 0.56, p < 0.001) and SE and registered nurses' clinical leadership (β = 0.52, p < 0.001). Registered nurses' clinical leadership was positively associated with quality of care (β = 0.32, p < 0.001) and negatively associated with AEs (β = -0.15, p < 0.001). Mediation analysis indicated a significant indirect effect of TL on registered nurses' clinical leadership through SE (B = 0.344, p < 0.001). SE was also indirectly associated with patient AEs through registered nurses' clinical leadership (B = -0.037, p = 0.003) and quality of nursing care (QOC) through registered nurses' clinical leadership (B = 0.147, p < 0.001). CONCLUSIONS: The study highlights the critical role that SE and nurses' clinical leadership play in explaining how TL is associated with improved patient care. These findings provide evidence to support policy and training initiatives that develop leadership frameworks, ensuring a more empowered and effective nursing workforce capable of delivering high-quality patient care.