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October 2022, Volume 72, Issue 10

Research Article

Impact of transformational leadership intervention of head nurses among front-line soldiers (staff nurses) working in government hospital

Khudija Mushtaq  ( Department of Nursing, Postgraduate College of Nursing Punjab, Lahore, Pakistan )
Muhammad Hussain  ( Lahore School of Nursing,University of Lahore, Lahore, Pakistan. )
Kousar Parveen  ( Lahore School of Nursing,University of Lahore, Lahore, Pakistan. )


Objective: To assess the impact of transformational leadership intervention among head nurses on staff nurses in improving job performance.


Method: The quasi-experimental study was conducted from December 2020 to August 2021 at the public-sector Services Hospital, Lahore, Pakistan, and comprised head nurses and staff nurses enrolled through multistage cluster random sampling technique. Sixteen weeks of transformational leadership interventions were organised in morning and evening shifts. Pre- and post-intervention assessments were done. Data was analysed using SPSS 25.


Results: Of the 576 subjects, 480(83.3%) were staff nurses and 96(16.6%) were head nurses. Transformational leadership intervention caused a significant improvement in staff nurses' job performance owing to improvement in the behaviour of the head nurses behaviour (p<0.05).


Conclusion: The study showed that staff nurses' performance significantly improved after transformational


Keywords: Transformational leadership, Head nurses, Frontline soldiers, Hospital, Job performance.

(JPMA 72: 1998; 2022)







Transformational leadership skills (TLSs) include Idealised Influence (II), Idealised Behaviour (IB), Individualised Consideration (IC), Intellectual Stimulation (IS) and Inspirational Motivation (IM). Head nurses apply TLSs as motivational and innovative approaches which enhance staff nurses' job performance. IS and IM are most effective in developing a vision of quality nursing care. Furthermore, TLSs have a great influence on staff nurses' behaviour to achieve healthcare organisation goals. Therefore, visionary leaders direct, motivate and stimulate their subordinates and engage them in the achievement of organisational goals. Regrettably, nurses lack the essential awareness about TLSs. There is a dire need to adopt different strategies to improve nurses' performance.

Transformational leadership (TL) is a leadership style which highlights passion, enthusiasm for vision and performing as the role model to earn the respect, trust and admiration of employees.1  Nursing managers who establish TL behaviour in hospitals have the greatest possibilities to build create an environment that improves high-quality nursing care and promote professionalism.2

A nurse is a trained person who provides care to the sick and the wounded. Therefore, all health organisations need qualified, experienced and efficient nurses who may provide quality care to patients efficiently and effectively, especially in public-sector hospitals. The hospital is an In hospitals, head nurses are team leaders supervising the clinical settings.3

Head nurses are the organisers, managers and primary administrators of a nursing team (NT). In Pakistan, all the nurses are registered with the Pakistan Nursing Council (PNC), but head nurses hold higher position, rank, more power and authority than registered nurses. TL knowledge among head nurses not only improves their own quality, work efficiency, and performance, but alleviates the level of the whole NT.4  

A cross-sectional study noted that the knowledge and awareness levels of the head nurses about TL could affect the quality of nursing care in hospitals. Such changes can be effected through improved performance of the head nurses that can be made using TL knowledge.5

There is a dire need to provide specific training about leadership knowledge and skills.6  The motivational factor of TL and management not only reduces absenteeism rate, but also improves job satisfaction, job performance and patient progress.7  Therefore, TL knowledge and its implementation have the strongest relationship with job performance and a higher level of trust.8

TL focuses on actual problems and shapes the performance of employees to attain organisational goals efficiently and effectively.9  TL is one of best styles to improve the performance of individuals.10

The role of every manager is to be a leader instead of being just a manager.10 TL is an application of innovation and motivation.11,12 Evidence shows that the role of TL has great importance in the success of organisation and performance.13  Work performance of nurses depends on trustworthy transformational leaders.14

Performance is a prescribed level of success or outcomes of a person within a certain period of time in carrying out his/her responsibilities compared with various, such as work results or targets that have been strong-minded in advance and agreed upon.15  The performance of nurses is associated with TL knowledge and skills, and organisational performance depends on head nurses' TL knowledge. Therefore, TL learning is necessary for the improvement of quality nursing care.16

A randomised controlled intervention study was conducted at the Tehran University of Medical Sciences (TUMS) on head nurses (n=110) and 660 registered nurses working in teaching hospitals. After the TL intervention, a significant improvement in the score of the interventional group (p<0.0001) was noted compared to the baseline.17

TL enhances motivation which results in significantly improving nurses' job performance as head nurses.18  Transformational nursing leaders are capable of improving organisational goals according to the patients' needs by individualised consideration and team development to achieve organisational goals.19

A study conducted in the telecommunication sector showed positive relationship of TL with IM.20

According to international studies, the World Health Organisation (WHO) estimates that 3-16% patients treated in hospitals are affected by adverse procedures.21  Poor performance of team leaders, like head nurses, is an independent cause of failure of many systems alongside the performance of staff nurses.21,22 Staff nurses are frontline soldiers in a healthcare setting, but without TL knowledge and skills, they cannot perform effectively. Studies have shown that positive and innovative TL is associated with work performance significantly.4,23 TL knowledge and its implementation have positive results related to nursing performance.24

The performance of employees is influenced by TL knowledge both directly and indirectly.25

Deteriorating performance of healthcare providers require TL for improvement, especially among nurses working in a public-sector setting. The current study was planned to assess the impact of TL intervention among head nurses on staff nurses in improving job performance.26


Subjects and Methods


The quasi-experimental study was conducted from December 2020 to August 2021 at the public-sector Services Hospital, Lahore, Pakistan, after the approval from the ethics review committee of the University of Lahore. A multifactor leadership questionnaire having IM and IS domains was used for evaluating the behaviour of head nurses, whereas for the staff nurses, a TL nurses' job performance observational checklist.27  Training programmes comprised presentations, role plays and scenarios that were prepared on the basis of literature and textbooks.28

The sample size for head nurses was calculated with 96% confidence level and 9% margin of error. Expected prevalence of post-adequate was 71.8% among the head nurses.29  A multistage cluster random sample of staff nurses working under the head nurses therefore one head nurse was responsible for the supervision of 5 staff nurses in one unit (Figure-1). Those included were female nurses aged 25-60 years doing both morning and evening shifts with a minimum experience of 5 years.

The job performance of staff nurses was measured with 41 items on a 3-point Likert scale ranging from 'incompetent', 'need improvement' and 'competent' options. The second questionnaire statement scored 1 mark for 'incompetent', 2 marks for 'need improvement', and 3 marks for 'competent'. The performance was considered competent if the scores were >68% and <68% scores were considered incompetent, and the mean score of each component was subsequently calculated by dividing the sum of all scores by the number of items.29,30 The reliability was checked using Cronbach's alpha coefficient test (r=0.89 and 0.96).

Baseline data was collected before the TL intervention, and after 16 weeks of intervention, data was collected again. The intervention comprised 6 sessions per week, with each session lasting one hour.

The principal researcher was given the intervention to the head nurses and the head nurses imparted TL education on the staff nurses for the improvement of job performance and quality of care. A total of 6 groups were made having 16 head nurses in one groups and a total of 30 groups were formed having 16 staff nurses in each group. All the subjects were given a code to maintain confidentiality and privacy.

Principal candidate organized training sessions for head nurses and then head nurses implemented their learned skills on staff nurses for the improvement of clinical performance. TL lectures were delivered in the class room of Surgical Unit 1 and the lectures were delivered by the principal researcher. The Principal researcher used different methods of teaching, such as lectures, group discussions, and brain-storming. Instructional media included handouts that were distributed to all the participants.

Data was analysed using SPSS 25. Descriptive statistics were reported as frequencies, percentages, mean and standard deviations. Paired sample t-test was used for inferential statistics. P<0.05 was considered statistically significant.




Of the 576 subjects, 480(83.3%) were staff nurses and 96(16.6%) were head nurses. Among the staff nurses, 303(64%) were aged 25-35 years, 418(87%) were married, 397(82%) had completed Bachelor of Science in Nursing, 363(76%) had 11-20 years of professional experience and 90(19%) were associated with operation theatres (OTs) (Table-1).

The difference in mean IM and IS values post-intervention was significant compared to the baseline, and the effect size was found to be large (Table-2).

Also, the difference in terms of hospital behaviour expectation, nursing process and quality of care was significant with a large effect size (Table-3).




TL is a visionary and modern leadership style which faces challenges with wisdom and insight. Therefore, the practice of this style could enhance nurses' performance. Hence, the organisational goals would be achieved effectively and efficiently.29,30

With a study14 reported that IS and IB had significant improvement in job performance.

The current study indicated there was significant improvement in mean values related to IM and IS dimensions of TL style, which is in line with literature.32

A study indicated that IM and IC had lower values than IS.33

The present study found highly significant improvement related to staff nurses' job performance, nursing process and quality of care, showing that there was intrinsic motivation, intellectual stimulation, individual coaching, continued training, constructive feedback, and presence of follow-up for nurses' performance under the supervision of motivated head nurses. Similarly, a study34  asserted that when the leaders provide support, motivation and a positive environment, the subordinates themselves perform with full devotion. Another study reported similar findings.35

In terms of limitations, the current study was held at a public-sector health facility and comprised only female nurses. The situation might be different in private hospitals and among male nurses. The study can be replicated on a large and diverse sample for better generalisation.

In the light of the findings, however, it is recommended that TL training programmes for head nurses should be organised because a wide range of strategies can be adopted and implemented in any healthcare organisation to support nurses grow as leaders at all levels.




TL-aware head nurses could influence staff nurses' job performance, nursing process and quality of nursing care.


Disclaimer: None.


Conflict of Interest: None.


Source of Funding: None.




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