Transformational leadership and patient care quality: exploring the mediating roles of structural empowerment and nurses’ clinical leadership – a cross-sectional study

Background:<br/>Effective leadership is critical in driving and motivating registered nurses to provide high-quality patient care. A link between effective transformational leadership in nursing and improved patient care outcomes has been established, but it is unknown how this association is affected.<br/><br/>Aim: <br/>To examine the relationships between transformational leadership (TL), structural empowerment (SE), registered nurses’ clinical leadership (CLS), and patient care outcomes.<br/><br/>Methods: <br/>This quantitative cross-sectional study was conducted in a government tertiary hospital in Saudi Arabia, with 1,038 registered nurses clustered under 28 head nurses. Instruments included the Multifactor Leadership Questionnaire, Conditions of Work Effectiveness Questionnaire II, Clinical Leadership Survey, and self-reported measures of patient adverse events and nursing care quality. Data was analysed using SPSS version 28 and R 4.3.3 packages "lavaan", "semPlot", and "semTools" for Multilevel Structural Equation Modelling (MSEM).<br/><br/>Results: <br/>Six hundred sixty-four surveys (response rate = 70%) were analysed. Multilevel analysis showed a significant positive association between transformational leadership and structural empowerment (β = 0.56, p &lt; 0.001) and between structural empowerment and registered nurses’ clinical leadership (β = 0.52, p &lt; 0.001). Registered nurses’ clinical leadership positively affected quality of care (β = 0.32, p &lt; 0.001) and was negatively associated with adverse events (β = −0.15, p &lt; 0.001). Mediation analysis indicated a significant indirect effect of transformational leadership on registered nurses’ clinical leadership through structural empowerment (B = 0.344, p &lt; 0.001). Structural empowerment also had a significant indirect effect on patient adverse events (AE) through registered nurses’ clinical leadership (B = −0.037, p = 0.003), and on quality of nursing care (QOC) through registered nurses’ clinical leadership (B = 0.147, p &lt; 0.001).<br/><br/>Conclusions: <br/>The study highlights the critical role that structural empowerment and nurses’ clinical leadership play in realising the positive benefits of transformational leadership on improving 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.