Electronic Thesis and Dissertation Repository


Doctor of Philosophy




Dr. Heather Laschinger

2nd Supervisor

Dr. Carol Wong

Joint Supervisor


Leadership is widely believed to be pivotal to providing high quality patient care and ensuring favourable organizational outcomes. To understand how nursing leadership affects patient outcomes, it is important to explore the mechanisms/ processes through which leaders produce desired patient outcomes. The purpose of this study was to examine how nurse manager use of transformational leadership behaviours creates empowering work environments that foster clinical leadership practices at the bedside, and ultimately, improve nurse and patient safety outcomes.

Bass’s (1985) transformational leadership theory provided the theoretical framework for the research. Transformational leadership behaviour was hypothesized to have positive effects on workplace empowerment and staff nurse clinical leadership and, in turn, lead to job satisfaction and lower frequency of adverse patient outcomes.

A non-experimental cross-sectional design involving survey data was used to test the hypothesized model in a random sample of Registered Nurses (n = 1,000) working in acute care hospitals in Ontario, Canada. Participants received a mail survey package that included a letter of information, study questionnaire, pre-paid envelope and a link to an online survey option. To optimize response rates non-responders received a reminder letter four weeks after the initial mailing, followed by a second survey four weeks later. Descriptive statistics and scale reliabilities were analyzed. Using structural equation modeling with maximum likelihood estimation in Mplus, the final model fit the data acceptably: χ2 = 959.309, df = 428, p = .001, CFI = .915, TLI = .908, RMSEA = .052, SRMR = .053. Transformational leadership was significantly associated with decreased adverse patient outcomes and increased job satisfaction through structural empowerment and staff nurse clinical leadership behaviours.

The findings provided support for the theoretical relationships between transformational leadership and nurse and patient safety outcomes. The results of this research indicate that a more complete understanding of what drives desired patient outcomes may need to include a focus on how to empower nurses and foster clinical leadership practices at the point of care. By creating empowering work environments, transformational leaders are providing opportunities for nurses to discover innovative approaches to do their work, which could lead to higher levels of satisfaction and quality care.

These findings provide contributions to the burgeoning literature on transformational leadership and its influence on nursing work environment and patient safety outcomes. The evidence from this research supports extending transformational leadership theory to incorporate structural empowerment and clinical leadership as mediators in the relationship between transformational leadership and nurse and patient outcomes. Findings from the research can be used to create theory-based strategies to enhance professional development of managers and inform policies to transform the work environments of nurses.