ISSN: 2456-8090 (online)

DOI: 10.26440/IHRJ/0602.05533

An Integrative Review of Transformational Leadership Style and Burnout: Implications for Nurse Leaders

LATIFAH ALENEZI*¹, GORDON LEE GILLESPIE², CAROLYN SMITH³

Cite this article as:

Alenezi L, Gillespie GL, Smith C.  An Integrative Review of Transformational Leadership Style and Burnout: Implications for Nurse Leaders. Int Healthc Res J. 2022;6(10):RV8-RV18. https://doi.org/10.26440/IHRJ/0607.10576

Author Affiliations:

1. Ph.D Student, University of Cincinnati College of Nursing, 3110 Vine St, Cincinnati, OH 45221
2. Ph.D, Professor & Interim Dean; Director Occupational Health Nursing Program, University of Cincinnati
3. Associate Professor, Academic - University of Cincinnati College of Nursing

Contact Corresponding Author at: alenezle[at]mail[dot]uc[dot]edu

ABSTRACT

INTRODUCTION: Transformational leadership improves the motivation and performance of others through different ways. Nurse leaders can use prior evidence to reimagine how transformational leadership can be applied in nursing while considering the uniqueness of nursing context vs other contexts. Nurse leaders additionally need to pay attention to the negative downside of transformational leadership on leaders themselves because it may have significant consequences on nurse leader burnout.

PURPOSE: To review the evidence and determine how transformational leadership characteristics are associated with burnout among nurse leaders.

MATERIALS AND METHOD: An integrative review of transformational leadership in nursing and nurse leader’s burnout was conducted using Whittemore and Knafl’s (2005) methodology. PubMed and Google Scholar were used in the literature search. Multiple combinations of the keywords and phrases “transformation leadership,” “nursing leadership,” “transformational leadership and burnout,” or “burnout among nurse leaders” were used for the literature search. To capture all articles relevant to this review, the inclusion criteria were set to peer reviewed and English articles published between 2002 and 2020 that reported on transformational leadership and nurse leader’s burnout.

RESULTS: Taking into consideration the main findings, their common meanings were organized and integrated as themes including transformational leadership in nursing, burnout of nurse leaders, and burnout of transformational leaders.

CONCLUSION: This integrative review explored how transformational leadership might be associated with burnout amongst nurse leaders. Overall, transformational leadership style was established as an effective leadership style at the organizational and employee levels in terms of, for example, job satisfaction. Literature showed that transformational leadership style has an association with burnout among leaders from contexts other than nursing. For nurse leaders, how this leadership style has an association with burnout needs to be investigated. 

KEYWORDS: Transformational Leadership, Burnout, Nurse Leaders, Nursing

INTRODUCTION

Transformational leadership is a particular leadership approach wherein the leader enhances the interest among employees to view their work from a different standpoint (Bass & Avolio, 1994). Although many leadership theories have been studied greatly, transformational leadership has been the most supported theory (Avolio et al., 2009). Additionally, this leadership style is one of the five Magnet components that help a hospital get and maintain Magnet status (ANA, 2010). Despite its importance and its many benefits on employees (Wang et al., 2021), it is not without some disadvantages especially for leaders themselves. 

Some studies done in contexts other than nursing have investigated the negative impacts of the transformational leadership style on leaders themselves (Arnold et al., 2015). This indicates a need for more research in the nursing context, as leadership tasks vary between nursing and other industries. Broadly speaking, transformational leadership is when a leader can transform followers’ thoughts and actions towards higher potential, morale, and ethical standards (Bass & Avolio, 1994). Connelly and Arnold (2011) suggested that leaders who aspire to be transformational may consider adapting this style of leadership to take the advantage of its benefits while mitigating the psychosocial stress associated with leadership demands and requirements. While acknowledging the importance of transformational leadership style, nurse leaders’ wellbeing needs to be looked at. Burnout among nurse leaders as an aspect of wellbeing will be discussed in this review. 

Within nursing, leadership roles were found to be demanding, and personnel filling this role are susceptible to burnout (Kelly et al., 2019). Nurse leaders are particularly exposed to emotional exhaustion, which is an aspect of burnout (Cao & Naruse, 2019). Burnout is defined as a state of continuous psychological stress within work life (Leiter & Maslach, 2009). When nurse leaders experience burnout, or are at risk of burnout, the work environment is put at risk, which has negative impacts on staff nurses (Flynn & Ironside, 2018). Nurse leaders, having the most demanding roles in the hospital environment, may consider leaving their positions (Warden et al., 2021). 

Although some researchers have investigated the relationship between the transformational leadership style and burnout in different sectors, research among nurse leaders is limited. Among hospitality managers, transformational leadership style was negatively related to emotional exhaustion and depersonalization as aspects of burnout (Zopiatis & Constanti, 2010). Leaders who employ transformational leadership style would likely have difficulty expressing negative feelings such as anger (Bass & Avolio, 1994). Based on transformational leadership theory, displaying negative emotions is perceived as inappropriate for the role model engaging in transformational leadership (Bass & Avolio, 1994). However, when workers are not able to express emotions, adverse health outcomes such as burnout can result (Zapf, 2002). 

Within sport field, a study found that one of the influencing factors for perceived burnout among leaders is the demands associated with the transformational leadership style especially if a leader has low emotional intelligence score. This is when a coach or a leader has poor skills of perceiving, interpreting, understanding, and managing emotions in themselves or others will not be a predominantly transformational leader (Ugrenovic et al., 2020). 

Among nurses who are not leaders, transformational leadership style was shown to be the most effective leadership style to decrease burnout (Liu et al., 2019). Given nurse leaders are critically needed to shape the environment through the direct interaction with their staff (Wei et al., 2018), the use of transformational leadership (TFL) style among nurse leaders and their personal burnout needs to be investigated. 

BACKGROUND

Burnout from work-related demands are central concerns because they cause a high cost related to the increased turnover among nurses (Diehl et al., 2021). Many studies have focused on burnout among nurses who are not leaders (Kelly et al., 2021), but burnout among nurse leaders needs to be studied due to their susceptibility to burnout associated with the high involvement in nursing management and quality control (Khalid, 2021). Nurse leaders are especially exposed to emotional exhaustion, which is one of the burnout hallmarks (Cao & Naruse, 2019). There are 30% of nursing leaders, including registered nurse (RN) leaders who held titles in the organizations as either clinical managers (CMs), senior CMs, or directors, leave their positions due to burnout and feeling exhausted with the work demands (Kelly et al., 2019). Nurse leaders experience a decrease in job satisfaction and a higher intent to leave because of experiencing high stress levels and burnout (Kelly et al., 2019). According to the World Health Organization (2019) burnout is defined as “an occupational phenomenon” when workers experience stress for a prolonged period within the workplace. Burnout is characterized by feeling exhausted, which decreases employee’s efficacy and increases feelings of detachment from their job (WHO, 2019).  In a sample of hospitality managers in Cyprus, transformational leadership was found to be negatively related to emotional exhaustion and depersonalization as aspects of burnout (Zopiatis & Constanti, 2010). The correlations and hierarchical regressions revealed a negative but moderate to insignificant association (Zopiatis & Constanti, 2010). However, this needs further exploration. 

Transformational leadership is based on a theory, which recognizes the need for promoting change within the organization through improving the motivation, spirit, and performance of the followers (Bass & Avolio, 1994). The four components of transformational leadership theory include charisma or idealized influence, inspirational motivation, intellectual stimulation, and personal attention or individualized consideration (Bass & Avolio, 1994). Charisma or idealized influence is when a leader makes personal sacrifices for employees’ benefits by going beyond an individual self-interest being a role model (Bass & Avolio, 1994). Inspirational motivation is by helping followers experience passion to reach the desired goals. For intellectual stimulation, transformational leaders encourage creativity and enhance employees to explore new ways to solve issues or improve a situation. Lastly, individualized consideration is when transformational leaders give personal attention, support, and encouragement to employees (Bass & Avolio, 1994). 

Transformational leadership is one of the five Magnet components that help a hospital get and maintain Magnet status (ANA, 2010). Additionally, transformational leadership theory has been widely advocated, it is important to understand whether transformational leadership can affect not only the followers but also leaders; and if so, why and under what conditions these relationships occur. Given that within the transformational-leadership literature, burnout is one of the most frequently measured well-being outcomes (Hildenbrand et al., 2018); researchers continue to call for further study of negative impacts of transformational leadership on leaders themselves so that they be more aware of the potential personal downside associated with it (Bass and Riggio’s, 2006). Investigating the association between transformational leadership and burnout of nurse leaders need to be done as there is insufficient information on the impact of transformational leadership on nurse leaders. 

PROBLEM IDENTIFICATION

Studies are limited in terms of reviewing the literature on the relationship between transformational leadership and nurse leader burnout. To address this gap in the literature, previous inconsistencies in the literature will be examined and calls for examination of link between TFL and burnout among nurse leaders will be answered. Studies exploring the association between leadership styles and burnout were done with nurses who are not leaders. However, nurse leaders also experience emotional exhaustion, which is one of the burnout hallmarks in addition to leadership tasks (Cao & Naruse, 2019). Therefore, examining burnout of transformational nurse leaders is needed. 

Researchers call to investigate the negative impacts of transformational leadership style for leaders themselves (Bass & Riggio, 2006). Responding to the calls, this proposed study tends to investigate how transformational leadership style might leave nurse leaders prone to burnout. Additionally, this integrative review (IR) would result in an understanding of the effect of transformational leadership style on burnout among nurse leaders, thus, considering transformational leadership attributes in their leadership practices would be aware of the negative effects on its connection with burnout. The incidents of burnout and emotional stress and exhaustion would be decreased among nurse leaders. Studying the correlation between transformational leadership style and burnout among nurse leaders will increase the chances of providing transformational leadership training modules and enacting transformational behaviors. Additionally, it addresses a change relevant to current modern practice in the form of transformational leadership. 

PURPOSE

The purpose of this IR is to review the evidence and determine how transformational leadership characteristics are associated with burnout among nurse leaders. Integrative review methodology was applied in efforts to obtain a comprehensive description of current knowledge and robust foundations for future knowledge generation. The investigation of the relationship between transformational leadership and burnout among nurse leaders addressed this question, what is the relationship between transformational leadership style and burnout among nurse leaders? 

MATERIALS AND METHOD

Design: Whittemore and Knafl's (2005) with its five-part integrative review methodology including problem identification, literature search, data evaluation, data analysis, and result presentation were used. The approach involved steps based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a four-phase flow diagram (Page et al., 2021). 

Identification and Screening: A literature search was conducted in January 2022 using PubMed and Google Scholar. In PubMed there were multiple combinations of the keywords and phrases, which included (Transformational leadership OR "Leadership"[Mesh]) AND (Nurse Leaders OR Managers OR Executives OR Administrators "Nurse Administrators"[Mesh]) AND (Burnout OR "Burnout, Professional"[Mesh]). Whereas, in Google Scholar keywords included transformational leadership AND nurse leaders AND burnout. These terms were searched within abstracts, titles, and keywords. To capture all articles relevant to this review, the inclusion criteria were set to peer reviewed and English articles that reported on transformational leadership and leader’s burnout including nurse leaders. Although articles on burnout among nurse leaders are included, articles on employees’ burnout who are not leaders are excluded due to the scope of this integrative review. For example, a study examined the relationship between nurse leadership style and nurse burnout was excluded (Wei et al., 2020). Studies that described transformational leadership and burnout among leaders from disciplines other than nursing were included. Studies conducted for other leadership styles were excluded if they didn’t include a transformational leadership component.  

A PRISMA flow diagram (figure 1) was developed based on the literature review procedures and article selection (Figure 1). In total, 23 articles were populated in google scholar (n=18) and PubMed (n=5). In the search strategy, articles within reference lists were examined. Although articles on “transformational leadership” and “nurse leader burnout” are included in this review, articles on “employee burnout” were excluded. Studies that described a mixed sample of leaders from different industries other than nursing were included only if they used transformational leadership style in their work. Only 11 articles met inclusion criteria and are discussed within the context of this review.  

Alernate link to tables/Figures (copy/paste link in a new browser window): https://drive.google.com/file/d/1rCBpD9hnUxsIRQHLvJwtjhhGB6gGXjJd/view?usp=sharing

Search Methods and Outcome: A literature table was created abstracting information from the 11 articles on study purpose and design, measures, sample, location, findings, and limitations (Table 1). This review included articles on the effectiveness of transformational leadership within nursing (n=3), burnout of nurse leaders (n= 4), and burnout of transformational leaders (n= 4). In this review, there were leaders from nursing (n=7), hospitality managers (n=1), collegiate coaches (n=1), mental health teams (n=1), and leaders from a wide range of industries (n=1). 

The articles derive from the United States (n=4), Cyprus (n=1), Canada (n=1), Japan (n=1), Belgium (n=1), Jordan (n=1), Pakistan (n=1), and a multinational study (n=1). Study designs included non-experimental cross-sectional study designs (Adriaenssens et al., 2017; Alloubani et al., 2019; Arnold et al., 2015; Asif et al., 2019;

Cao & Naruse, 2019; Lappalainen et al., 2019; Ugrenovic et al., 2020; Zopiatis & Constanti, 2010), large mixed methods study (Kelly et al., 2019), non-experimental prospective study design (Corrigan et al., 2002), and pre/post intervention study design (Ceravolo & Raines, 2019). 

The most common measures of burnout used among the 11 studies were the Maslach Burnout Inventory with confirmed validity and reliability (n=3), Oldenburg Burnout Inventory with confirmed validity and reliability (n=1), Copenhagen Burnout Inventory with confirmed validity and reliability (n=2), Professional Quality of Life with confirmed validity and reliability (ProQOL) (n= 1), and Japanese Burnout Inventory (J-BI) with confirmed validity and reliability (n= 1). 

The transformational leadership was measured using Multifactor Leadership Questionnaire (MLQ) (5x-Short) across five articles with confirmed validity and reliability (n=5). One article used the Finland version of Transformational Leadership Scale (TLS) with confirmed validity and reliability (n=1) and one other article used transformational leadership seven item scale developed by Carless et al. with confirmed validity and reliability (n=1). 

Quality Appraisal: Each article was rated by the first author according to the John Hopkins Level of Evidence and Quality Guide (Dang & Dearholt, 2017). This scale measured level of evidence on a scale of I-V. Level I represents experimental studies, level II represents quasi-experimental studies, and level III represents nonexperimental studies (Dang & Dearholt, 2017). Level IV and V are based on non-research evidence (Dang & Dearholt, 2017). Quality of papers was rated as high, good, and low. High-quality reports are articles with consistent generalizability and recommendations based on sound scientific evidence. Good-quality evidence is indicative of generally consistent results, sample size, control, and recommendation (Dang & Dearholt, 2017). Low-quality studies possess significant flaws that limit the conclusiveness of the report (Dang & Dearholt, 2017). 

All the articles in this review were rated at level III evidence and were of good quality (n=10) except for one article, which was rated as level II evidence with high quality (n=1). Most studies included in this review are older than five years because of the limited number of studies that fit the inclusion criteria. Six studies used non-probability sampling and five did not mention the sampling type.

Data Analysis and Presentation: Data were extracted from primary sources based on study characteristics and methods related to the concept of transformational leadership and leaders’ burnout. A summary form was completed with the following data extraction fields for each individual study: citation, design and method, sample and setting, major variables, measurements and tools, outcomes, and level of evidence. Data from the summary forms were used to critically synthesize and summarize findings across studies, presenting results in tabular format (synthesis tables). 

RESULTS

Taking into consideration the main findings, their common meanings were organized and integrated as themes including transformational leadership in nursing, burnout of nurse leaders, and burnout of transformational leaders. Three studies discussed transformational leadership within nursing (Alloubani et al., 2018; Asif et al., 2019; Lappalainen et al., 2019). Three studies talked about the impact of transformational leadership on burnout among leaders (Arnold et al., 2015; Zopiatis & Constanti, 2010; Ugrenovic et al., 2020; Corrigan et al., 2002). Four studies focused on burnout among nurse leaders (Kelly et al., 2019; Cao & Naruse, 2019; Adriaenssens et al., 2017; Ceravolo & Raines, 2019). 

TRANSFORMATIONAL LEADERSHIP IN NURSING

Using a cross-sectional descriptive study design in three private hospitals and three public hospitals, Alloubani et al (2018) investigated managers’ leadership styles, from the perspective of registered nurses, and its effects on the quality of nursing care. Transformational leadership style was found to be the most used leadership style by nurse managers who work in the private sector in comparison with the public hospital (Alloubani et al., 2018). Alloubani et al. (2019) found that there was a significant positive relationship among the transformational leadership and quality of nursing care (r= 0.87; p <0.001). Alloubani et al. (2019) also reported there was a significant positive relationship among the transformational leadership and job satisfaction (r= 0.81; p <0.001). Lappalainen et al. (2019) in their study from Finland using cross-sectional study design with 161 RNs showed that transformational leadership has a significant relationship with medication safety (r = 0.541; p < 0.001). 

A cross-sectional study design was used with 17 government hospitals and 600 registered female nurses in Pakistan, using structural equation modelling, reporting that transformational leadership has a significant relationship with structural empowerment (β = 0.57; p <0.01), and structural empowerment has a significant relationship with quality of care (β = 0.39; p <0.01) (Asif et al., 2019). Structural empowerment was found to be a mediator between leadership style and quality of care.  Additionally, transformational leadership was found to have a positive significant relationship with job satisfaction (β= 0.43; p <0.01), and job satisfaction has a significant relationship with quality of care (β= 0.23; p <0.01). Job satisfaction was found to be a mediator between leadership style and quality of care (Asif et al., 2019). 

Nurse leaders who use transformational leadership principles create a climate where employees have a high quality of care (Alloubani et al 2019; Asif et al., 2019). Nurse leaders that adopt transformational leadership see gains in staff satisfaction, which in turn may have an important effect (Alloubani et al, 2019; Asif et al., 2019). 

BURNOUT OF NURSE LEADERS

Increased amounts of stress contribute to high rates of burnout, staff and leader turnover, and decreased satisfaction amongst nursing leaders (Kelly et al., 2019). Approximately 30% of nursing leaders leave their positions due to burnout and feeling overwhelmed with the demands of work (Kelly et al., 2019). Kelly et al. (2019) carried out a mixed methods study with qualitative and quantitative data to explore burnout, stress, and compassion satisfaction in multiple levels of nursing leadership. The Professional Quality of Life (ProQOL) was used to measure burnout, stress, and compassion satisfaction. Six hundred seventy-two nurse leaders, across 29 hospitals were sent out an electronic survey with three parts to evaluate demographics, results of the ProQOL, and questions regarding work satisfaction (Kelly et al., 2019). A phone interview was also scheduled with nurse leaders for the qualitative portion of the study, to inquire about organizational satisfaction, satisfaction with work, satisfaction with their work life balance, and recognition. The results showed that the overall job satisfaction increased with each level of nursing leadership, with directors demonstrating the least amount of burnout and stress, proposed to be due to the possibility of skill-attainment by the experience of being in leadership over an extended period (Kelly et al., 2019). Clinical nurse managers showed the highest levels of stress and burnout with those having the least amount of experience being higher than others (Kelly et al., 2019). The role of managing individuals was associated with emotional drain leading to compassion fatigue, and that a work-life balance was crucial to effective leadership (Kelly et al., 2019). Nurse managers with constant exposure to an environment of stress will ultimately experience burnout (Kelly et al., 2019). Hence, continuous exposure to stress is linked to burnout in leaders contributing to decreased job satisfaction and increased turnover rates (Kelly et al., 2019). Among many contributors of burnout among nurse leaders, Kelly et al. (2019) highlights work life balance, compassion satisfaction, as well as overall satisfaction with work as important factors for decreasing stress. 

A study in Japan using cross-sectional study design on 93 home-visiting nurses has shown that nursing managers are especially exposed to emotional exhaustion (EE) (Cao & Naruse, 2019). Low levels of personal accomplishment burnout dimension were especially likely to occur when workers were subjected to overload and had a high degree of responsibility. This was often the case for nursing managers, who thus presented a strong predisposition towards problems in this respect (Cao & Naruse, 2019). Among other sociodemographic factors, burnout was related to age (Cao & Naruse, 2019). Thus, the risk of developing burnout was especially acute among women aged 40−50 years old. Furthermore, full-time workers were more likely to suffer burnout than those working part time (Cao & Naruse, 2019). Nursing managers often bear a heavy workload, and this is a major risk factor for burnout among them (Cao & Naruse, 2019). In addition to providing nursing care, they need to establish productive relationships with other personnel, both within the hospital and elsewhere, and make good use of health and social resources (Cao & Naruse, 2019). Time pressure of having insufficient time to complete the required job arrangement is positive predictor for emotional exhaustion and depersonalization (p < 0.001). In which nurse managers’ relational coordination of the quality of collaborative relationships among practice members is negatively related to depersonalization (Cao & Naruse, 2019). There is a significant relationship between nurse managers’ time pressure and relational coordination based on the effects of exhaustion and  depersonalization. When nursing managers experience burnout, they cannot properly meet the needs of their patients, which results in lost productivity and feelings of dissatisfaction (Cao & Naruse, 2019).  

To study predictors of occupational well-being in 318 first-line nurse managers a cross-sectional study design was used to examine various relationships between predictors and outcomes. Among other sociodemographic factors, burnout was related to age (Adriaenssens et al., 2017). Thus, the risk of developing burnout was especially acute among women aged 40−50 years old. Furthermore, full-time workers were more likely to suffer burnout than those working part time (Adriaenssens et al., 2017). Additionally, failing to receive the necessary support from co-workers, subordinates and superiors had a strong negative impact on nursing managers and was directly associated with the rejection of their role as a nursing manager (Adriaenssens et al., 2017). 

To measure the impact of a series of mindfulness workshops on nurse managers’ perception of professional quality of life, burnout, and perceived wellness, a pre/post intervention design was conducted with 13 nurse managers (Ceravolo & Raines, 2019). The intervention was a weekly 60-minute group session led by a mindfulness expert for 8-weeks (Ceravolo & Raines, 2019). Findings showed that establishing productive relationships with other personnel, both within the hospital and elsewhere, and make good use of health and social resources are both considered as risk factors for burnout among nurse managers (Ceravolo & Raines, 2019). 

In addition, mindfulness-based interventions can significantly alleviate the degree of burnout experienced by nursing managers (Ceravolo & Raines, 2019). There were significant positive changes in the scores on the compassion satisfaction (p = .002) and burnout subscales (p = .016) of the Professional Quality of Life scale, and on personal burnout (p = .023) and work-related burnout (p = .029) on the Copenhagen Burnout Inventory scale, following the mindfulness intervention. The 3-month follow-up scores on compassion satisfaction were higher but not statistically significant (p = .810). Scores on the burnout scales, while lower than the preintervention levels, were higher at the 3-month follow-up than immediately following the intervention (Ceravolo & Raines, 2019).

Overall, job burnout among nurse leaders can result from various factors.  Level of nursing leadership was found to be a burnout influencer with directors demonstrating the least amount of burnout and with clinical nurse managers showing the highest levels of stress and burnout (Kelly et al., 2019). Other factors include constant exposure to an environment of stress (Kelly et al., 2019), work overload (Cao & Naruse, 2019), and age especially among those aged 40 to 50 years old (Adriaenssens et al., 2017; Cao & Naruse, 2019). Other studies found that working full time (Adriaenssens et al., 2017; Cao & Naruse, 2019), time pressure (Cao & Naruse, 2019), and need for support from coworkers (Adriaenssens et al., 2017) are other types of burnout factors. 

BURNOUT OF TRANSFORMATIONAL LEADERS

Studies done in contexts other than nursing investigated the negative impacts of the transformational leadership style on leaders themselves (Arnold et al., 2015). There is empirical evidence that leadership strategies are linked to leaders’ own levels of strain (Arnold et al., 2015). Transformational leaders are suggested to use different emotion regulation strategies to meet the demands of this style. Some of these emotion regulation strategies such as adapting and altering the way leaders think, predict resource drain and burnout (Arnold et al., 2015). For leaders, it has been argued that engaging in transformational leadership is a resource drain (Arnold et al., 2015). However, as the relation between transformational leadership and leader strain was negative, results indicate that leaders who highly engage in transformational behaviors would experience less strain. 

Other studies found that transformational leadership is an influencing factor for perceived burnout among leaders in the sport field because of the requirements associated with the transformational leadership style (Ugrenovic et al., 2020). A total of 244 (n = 140 male, n = 103 female, n = 1 undisclosed) coaches participated from across all three national collegiate athletic association (NCAA) divisions. The results indicated that there was a significant negative relationship between transformational leadership style and perceived burnout (r = -.24, p = .000). 

Among mental health teams using a prospective non-experimental study design, the relationship between leadership styles and staff burnout including 236 leaders were examined (Corrigan et al., 2002). Results showed that idealized influence, inspirational motivation, and individual consideration dimensions of transformational leadership were significantly negatively associated with the emotional exhaustion dimension of burnout and positively associated with personal accomplishment. Intellectual stimulation was not significantly positively correlated with emotional exhaustion (Corrigan et al., 2002). One strength about this study that the researcher considered the four components of transformational leadership style including charisma, inspirational motivation, intellectual stimulation, and individualized consideration. This pattern of correlations might suggest that different aspects of transformational leadership have unequal effects on burnout for leaders (Corrigan et al., 2002). 

To explore whether transformational, transactional, or passive/avoidance leadership behaviors are prone to burnout, a quantitative non-experimental study design was used. This study examined differences exist between the leader’s level of burnout and leadership style of 131 hospitality managers working in Cyprus (Zopiatis & Constanti, 2010). Findings revealed that transformational leadership has a significant positive association with personal accomplishment and is negatively related to emotional exhaustion and depersonalization which are considered as burnout dimensions. This study endorsed that a transformational leader, being highly considerate of employees, provides employees with ability to handle challenging aspects of work and reduces the likelihood of employees experiencing emotional exhaustion. (Zopiatis and Constanti 2010). Whereas among the hospitality managers, transformational leadership style was negatively related to emotional exhaustion and depersonalization as aspects of burnout (Zopiatis & Constanti, 2010). 

Transformational leadership is not without some disadvantages especially for leaders themselves. For leaders, engaging in high-demanding transformational leadership was considered as a resource drain which predicts burnout experienced by leaders (Arnold et al., 2015). In the sport field, transformational leadership was negatively associated with transformational leadership, and this is when a leader has poor skills of managing emotions (Ugrenovic et al., 2020). Among mental health teams and among hospitality managers found that transformational leadership is negatively related to emotional exhaustion (Ugrenovic et al., 2020; Zopiatis & Constanti, 2010), negatively related to depersonalization (Zopiatis & Constanti, 2010), and positively associated with personal accomplishment (Ugrenovic et al., 2020; Zopiatis & Constanti, 2010). However, the course of action on how transformational leadership is connected to burnout for each of these studies needs further exploration (Arnold et al., 2015; Corrigan et al., 2002; Ugrenovic et al., 2020; Zopiatis & Constanti, 2010).

DISCUSSION

An extensive review of the literature suggested that transformational leadership is a term that is frequently and consistently used in nursing research. Using transformational leadership helps a leader to transform the organization, resulting in a great benefit to the organization, staff, and the patients (Alloubani et al., 2018; Asif et al., 2019; Lappalainen et al., 2019). Despite its importance and its many benefits on employees, it is not without some disadvantages especially for nurse leaders themselves. This integrative review addresses a clinically serious problem by understanding the effect of transformational leadership style on burnout among nurse leaders, thus, the chances of enacting transformational behaviors while mitigating its negative downsides will get increased. Transformational leadership trainers will consider this style’s negative aspects so that leaders will be aware of their own health and wellbeing while transforming and leading the organization. This integrative review investigates a gap of knowledge, which has not been studied, about the effect of leadership on burnout among nurse leaders. The study addresses a change relevant to current modern practice in the form of transformational leadership. Additionally, there is a call to investigate the negative impacts of transformational leadership style for leaders themselves (Bass & Riggio, 2006). Responding to the calls, this integrative review tends to investigate how transformational leadership style might leave nurse leaders prone to burnout. Although some research studies have investigated the relationship between transformational leadership style and burnout in different sectors, research among nurse leaders is limited. This indicates a need for more research in the nursing context. 

Burnout has been shown to have negative physical responses in the body resulting from increased demands placed on the individual (Ceravolo & Raines, 2019), which did not contradict the belief that transformational leadership requires extra efforts which is considered in the review as both resource depletion (Arnold et al., 2015) and a cause of emotional depletion (Kelly et al., 2019). This is because of that high-quality leader behaviors are in high need of leaders’ resources, which leads to resource depletion, and, consequently, to more strain for leaders. On the one hand, transformational leadership strategies may also influence leaders’ own health in the way that high-quality leader behaviors are particularly resource demanding for leaders (Arnold et al., 2015). This result seems to be counterintuitive to the theoretical rationale that posits that high-demanding transformational leadership behavior leads to more stress experienced by leaders (Arnold et al., 2015). 

Among nurse managers, how hard to keep coaching an individual on their performance was considered a source of emotional depletion by one of the leaders (Kelly et al., 2019). Individualized consideration is one of transformational leadership’s components which was found to be correlated to burnout among hospitality managers (Zopiatis & Constanti, 2010). Some others considered the challenges a leader encounters when trying to motivate staff as burnout contributors (Kelly et al., 2019). Kelly’s et al. (2019) finding does not contradict findings by Corrigan et al. (2002) that one of the transformational leadership components which is inspirational motivation was found to be significantly negatively associated with the emotional exhaustion dimension of burnout.

Other factors that impact nurse leader’s burnout were also included in the review. Increased amounts of stress were found to be a leading cause for high rates of burnout, staff and leader turnover, and decreased satisfaction amongst nursing leaders (Kelly et al., 2019). Among many factors that lead to burnout for nurse leaders, having the least amount of experience would lead to burnout more often (Kelly et al., 2019).

Effective ways to prevent burnout among nurse leader were included. To maintain a healthy working environment and prevent burnout among nurse leaders, possible interventions that may be effective could include senior officials lending their support and help to lighten managers’ responsibilities, especially those of an administrative nature, for example, by providing more auxiliary staff (Adriaenssens et al., 2017). Effective strategies to reduce negative impacts of transformational nurse leaders need to be investigated. 

STRENGTHS AND LIMITATIONS

These published studies helped in giving a detailed analysis and establishing the gaps identified in the topic for this review. Even though an absence of past studies complicates the research process, these studies have shown how leaders react to transformational leadership. The articles that were identified cover different aspects related to nursing and transformational leadership style which have been used in the past. They aid in developing a better understanding of the general concept of transformational leadership and burnout in nursing practice. This review addresses a gap in the literature and offers insight into outcomes of using transformational leadership style within nursing context. 

Although self-report is a generally accepted method used to determine transformational leadership style, a limitation common to most reviewed articles was the potential for self-report bias as nurse leaders’ reports were not validated with other resources. Self-report bias is making it difficult to identify the degree to which leaders use transformational leadership. Generalizability of findings are limited due to the use of non-random sampling in most of the studies and the variety of settings, particularly for countries other than the United States. The small sample size in some studies was another factor that limited the generalizability. 

Limitations of What the Author Was Able to Do: Search limiters narrowed the focus of this integrative review so that the information retrieved from the databases was limited according to the values selected. Using more than one limiter decreased the number of the articles in the search results such as the scholarly peer reviewed limits. There were some studies that did not show up in the databases that were used. Additionally, there were some studies that were used in this integrative review though they didn’t include appropriate keywords such as “nursing”. Articles from contexts other than nursing were included which limited the generalizability of findings to nursing field. 

Implications for Practice: The findings from this integrative review can be used by nurse leaders. Nurse leaders can undergo transformational leadership training and mentoring to improve their knowledge and skills in transformational leadership, while mitigating its negative connection with burnout. This will help to nurture individuals who possess the transformational leadership traits. Consequently, those within healthcare organizations can revise selection and promotional strategies for persons hired into leadership positions. They can use transformational leadership subscale to assess for transformational leadership skills and then Copenhagen Burnout Inventory can be used to assess how likely they are to experience burnout even though they are transformational leaders. This is because being transformational leaders is beneficial for the whole organization and at the same time how nurse leaders feel about practicing transformational leadership is also critical for their health and wellbeing. Healthcare organizations need to ensure that their nurse leaders are satisfied with their jobs and show minimal burnout levels. For this to be achieved, it is essential that these organizations take advantage of the results of this review and ensure that transformational leadership style is employed in their organizations. As discussed, the results of this review suggest that transformational leadership is an effective leadership style within nursing, but it has some negative aspects especially for nurse leaders. This conclusion could have implications for healthcare professionals including nurse leaders and healthcare organizations. Nurse leaders could practice transformational leadership to maintain the magnet status of a hospital while recognizing its stressful downsides. 

Future Directions: This integrative review has closed the overall literature gap that existed concerning the association between the transformational leadership style and burnout among nurse leaders. Future research might need to focus on the different management levels that exist among the nurse leaders, because the results may vary significantly. Different levels of management may lead to different results in relation to the topic of this integrative review. Additionally, future research concerning the same topic could continue to provide insightful information on the best transformational leadership training that could be employed to ensure that knowledge is put into action while controlling its potentially negative connection with burnout. Because a leader who is experiencing burnout will not be as effective, training modules are needed that will enable leaders to enact transformational behaviors. In this way even when nurse leaders are experiencing aspects of burnout such as emotional exhaustion or depersonalization, they can still be transformational while reducing the stressfulness of enacting transformational behaviors. 

CONCLUSION

This integrative review explored how transformational leadership might be associated with burnout amongst nurse leaders. Research on leadership styles and their relationship with employee’s burnout are in existence, but this review extends beyond that and provides information on transformational leadership as an influencing factor of burnout among nurse leaders. Overall, transformational leadership style was established as an effective leadership style at the organizational and employee levels in terms of, for example, job satisfaction and has an association with burnout among leaders. For nurse leaders, it needs to be investigated further. 

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© Latifah Alenezi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY-NC 4.0, which permits unrestricted use, distribution and reproduction in any medium, provided the use is not commercial and the original author(s) and source are cited.

Submitted on: 17-Dec-2022;  Accepted on: .30-Dec-2022