Journal of Advances in Medicine and Medical Research

34(12): 33 – 45, 2023; Article No.: JAMMR.92716

Transformational Leadership and Patient-Centered Care in Tertiary

Hospitals in Rivers State, Nigeria.
1Adetomi Bademosi; 2Hart Awa; 3Charles Tobin West
1,Department of Community Medicine, Faculty of Clinical Sciences, College of Medical sciences, Rivers State University, Rivers State,
Nigeria.
2Department of Marketing, Faculty of Management sciences, University of Port Harcourt, Port Harcourt, Nigeria
3Department of Community Medicine, Faculty of clinical sciences, college of medicine, University of Port Harcourt, Rivers State, Nigeria.

Abstract
The study examined the nexus between transformational leadership and patient-centered
care (measured by physical comfort and emotional support) in tertiary hospitals in Rivers
State. The theory of Planned Behavior and the quality-of-service features model
underpinned the study. The underlying philosophical paradigm is positivism, and the
research design is cross-sectional survey, while questionnaire was the instrument for data
collection. With a population of 1675, the sample size was scientifically determined to be 310
using the Krejcie and Morgan’s table. Also, Bowley’s (1926) proportional allocation was
applied. Structural Equation Modelling was deployed to test the hypotheses at 0.05
significance level. The results revealed that there is a positive and significant relationship
between transformational leadership and physical comfort and increase in transformational
leadership is associated with increase in emotional support. in tertiary hospitals in Rivers
State, Nigeria. Therefore, it is recommended that Management of tertiary hospitals should
increase the adoption of transformational leadership. This can be accomplished by
counselling and motivating others on what need to be accomplished, specifying the
importance of having a strong relationship and sense of purpose, spending time teaching and
coaching, displaying a sense of power and confidence, articulating a compelling vision of the
future and motivating others to follow.
Keywords: Transformational leadership, patient-centered-care, physical comfort,
emotional support, tertiary hospitals.
1. INTRODUCTION
In Nigeria, the healthcare industry is strategically placed to provide quality health services
in terms wellness and extended life expectancy. The idea of quality health services in the
healthcare industry involves patient-centered care (PCC), which is a function of the extent of
motivation and support received by the healthcare providers, as well as the availability of
medical facilities, and the relationship amongst medical providers with the patients
(Khairunnisa et al., 2019). In essence, PCC involves meeting the patient’s needs and
aspirations by respecting and integrating individual differences in times of healthcare
delivery. The patient-centered reports measure the quality of PCC, including the patient’s
experience and satisfaction with the care. However, the continual failure in the healthcare
sector seems alarming and attributable in part to weak priority on leadership capacity even
as O’Neil (2008) envisaged leadership as a key strategy for effective healthcare system’s
design and/or redesign. Furthermore, in hospitals, the demands placed upon leaders have
become more complex, and the need for different forms of leadership is increasingly evident.
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34(12): 33 – 45, 2023; Article No.: JAMMR.92716
Particularly, transformational leadership style motivates the workforce or followers to do
more than they originally intended or often more than they thought possible (Cummings et
al., 2009). The dearth of scholarship on leadership styles related to the hospitals (Janssen,
2004), lack of health workers’ training on leadership perspectives (Joshi, 2017), and lack of
leadership models that are healthcare compliant (Joshi, 2019) leave the healthcare industry
without direction and inform urgent inquiries. However, most of the extant studies
(Cummings et al., 2019; Alloubani et al., 2019; Polit & Beck, 2016; Abdelhafiz et al., 2016)
focused their studies on nurses almost to the neglect of other healthcare professionals, such
as physicians, physiotherapists, pharmacists, and laboratory scientists. Therefore, the
motivation behind studying healthcare environment rests on extending inquiries and the
fact that previous inquiries (Cho et al., 2003; Sfantou et al., 2017; Alloubani et al., 2019;
Estabrooks et al., 2005; Baker et al., 2004) link the characteristics and effectiveness of
healthcare environment to leadership styles in terms of relationship among healthcare
workers which ultimately leads to quality healthcare delivery. Therefore, this study seeks to
close the lacuna in literature by critically examining transformational leadership style and
how it affects patient-centered care in tertiary hospitals in Rivers State, Nigeria.
2. METHOD
The philosophical context of the study, is positivism. Positivist ontology is a philosophical
realism linked to objectivity and deductive theory, and which unravels definable and
quantifiable social facts through systematic observations and interactions in a natural
setting. In essence, positivist paradigm is adopted because the epistemology underlying
descriptive and quantitative paradigm is to generate reality by natural mechanism,
specifically, explanatory and cross-sectional survey through the use of self-reported
questionnaire was the resign design adopted essentially because the researcher could not
control or manaipulate the variables. The population of any study defines the universe or the
sum total of the units of analysis that conforms to the laid-down standards. The study targets
the tertiary hospitals (UPTH and BMH/RSUTH) in Rivers state, because all things being
equal, tertiary hospitals host greater number of qualified medical professionals, and have
more budgets and facilities than other classes of healthcare givers in the state. The heads of
the various departments within the hospitals and the unit heads in different units under the
departments, as well as patients receiving medical care will be studied. Further, the unit
heads that qualify to take part in the exercise must be in charge of at least three subordinates
and must have a minimum of one-year experience in the current post. For the patients, the
study will focus on adult patients (18 years and above) that are conscious and well-oriented
at the point of discharge after having received the care. With a population of one thousand,
six hundred and seventy five (1675), the sample size was scientifically determined to be
three hundred and ten (310) using the Krejcie and Morgan (1970) table as a guide. However,
because we are interested in different groups of audience, Bowley’s (1926) proportional
allocation was applied.
The simple random sampling was used to ensure that each member of the accessible
population has equal chance of being selected. The questionnaire was the source of data
collection. A total of 310 copies of the instrument were administered, out of which a total of
255 copies were retrieved, representing 82.26% of actual distribution rate. However, 55
copies representing 17.74% were not retrieved, as the concerned respondents could not
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34(12): 33 – 45, 2023; Article No.: JAMMR.92716
create time to complete them. Of the 255 copies of the instrument retrieved, 24 copies,
representing 7.74% were not usable due to missing responses. In all, 231 copies of the
instrument, representing 74.52% were retrieved and usable. The hypotheses were tested at
0.05 level of significance, using the Structural Equation Modelling (SEM). SEM is made up of
measurement and structural models; whereas, measurement model depicts the relationship
between the latent factors and their observed measures (that is, CFA model) the structural
model depicts relationship amongst the latent factors themselves. The hypothesized models
are tested in a simultaneous statistical examination through the whole system of variables
that decides the degree to which it is consistent with the data. When the goodness-of-fit is
satisfactory, SEM contends with the plausibility of the hypothesized relationship among the
distinguished factors. The instrument was subjected to test of reliability with the following
Cronbach’s alpha values: Transformational leadership (0.825), physical comfort (0.853) and
emotional support (0.925). As recommended by Nunnally and Bernstein, (1994) an alpha
value of 0.7 and above indicates reliability of the measured constructs.
3. RESULTS
Table 1 shows the demographic distribution of the study participants.
Table 1: Demographic distribution of Participants
Frequency Percent
Variables (n=231) (%)
Age of Respondent
20 - 29 28 12.1
30 - 39 67 29
40 - 49 102 44.2
50 - 59 29 12.6
60 and above 5 2.2
Occupation
Medical Doctor 160 69.3
Nurse 5 2.2
Pharmacist 29 12.6
Laboratory Technician 37 16
Clinical experience
Less than 5 years 56 24.2
6-10 years 37 16
11-15 years 82 35.5
16-20 years 16 6.9
Above 20 years 40 17.3

The measurement model is in two stages : (i) the examination of the goodness of fit indices
after the indicators have been loaded into the latent variable, and (ii) the interpretation of
the parameter estimates. The suggested goodness of fit indices provided in Hu and Bentler
(1999), states that acceptable model fit is defined by the following criteria: RMSEA (≤0.6),
SRMR (≤0.8), CFI (≥0.95), TLI (≥0.95), GFI (≥0.90), NFI (≥0.95) PCLOSE ( ≥0.5) and AGFI
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34(12): 33 – 45, 2023; Article No.: JAMMR.92716
(≥0.90) (Byrne, 2013). Where : RMSEA = Root Mean Squared Error of Approximation, CFI =
Comparative Fit Index, TLI = Turker-Lewis index, GFI = Goodness-of-Fit-Index, AGFI =
Adjusted Goodness-of-Fit-Index, SRMR = Standardized Root Mean Residual, NFI = Normed
Fit Index and PCLOSE = Probability of Close Fit. Moreso, Carmines and McIver, (1981)
suggested that the value of ratio of the χ² statistic to its degree of freedom (χ²/df) , should
be less than 5 or preferable less than 3 to indicate an acceptable fit ( χ²/df <5 preferable <3 ).
In the case of parameter estimates, factor loading (Standardised regression weight) should
be greater than 0.5 and preferably above 0.7 (Byrne, 2010). The measurement model (CFA
model) rides on the common factor model which is represented by the fundamental
equation:

yj = λj1 ŋ1 + λj2 ŋ2 + . . . + λjmŋm + εj

/

Figure 1: Measurement Model of Transformational Leadership

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34(12): 33 – 45, 2023; Article No.: JAMMR.92716
Table 2: Measurement Model Analysis of Transformational Leadership
Model Chi- χ²/df NFI TLI CFI RMSEA Variable Factor Error
Square(df), Loading VAR
Estimates

Transf. 33.591, 1.679 0.951 0.966 0.956 0.78 TRF1 0.930 0.87
LeLleadership (20df)

TRF2 0.935 0.87

TRF3 0.872 0.76

TRF4 0.656 0.43

TRF5 0.754 0.57

TRF6 0.799 0.64

TRF7 0.471 0.22

TRF8 0.790 0.62

The results of the goodness of fit indices indicated acceptable fit to the data for one-factor
model (chi-square (20df)=33.591, χ²/df=1.679, RMSEA=0.78, CFI=0.956, NFI=0.951 and
TLI=0.966). Table 2 summarized the goodness of fit indices, the factor loading estimates and
the error variances. Factor loading estimates revealed that seven indicators were strongly
related to latent factor -transformational leadership and were statistically significant. The
indicators TRF1-TRF6 and TRF8 had factor loadings of 0.93, 0.94, 0.87, 0.66, 0.75, 0.80 and
0.79 respectively and error variances of 0.87, 0.87, 0.76, 0.43, 0.57, 0.64 and 0.62
respectively. However, the weak indicator TRF7 was deleted from the model, because the
weak loading was 0.22. The first six and eighth freely estimated standardized parameters
were statistically significant. These parameters are consistent with the position that these
are reliable indicators of the construct of transformational leadership.

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34(12): 33 – 45, 2023; Article No.: JAMMR.92716

Figure 2: Measurement Model of Physical Comfort

Table 3: Measurement Model Analysis of Physical Comfort
Model Chi- χ²/df NFI TLI CFI RMSEA Variable Factor Error
Square(df), Loading VAR
Significance Estimates
Physical (15df) 2.341 0.943 0.937 0.958 0.104 ES1 0.810 0.66
Comfort =35.119

ES2 0.910 0.83

ES3 0.833 0.69
ES4 0.509 0.26
ES5 0.540 0.29
The results of the goodness of fit indices indicated acceptable fit to the data for one-factor
model (chi-square (15df)=35.119, χ²/df=2.341, RMSEA=0.104, CFI=0.958, NFI=0.943 and
TLI=0.937). Table 3 summarized the goodness of fit indices, the factor loading estimates and
the error variances. Factor loading estimates revealed that five indicators were strongly
related to latent factor -physical comfort- and were statistically significant. The indicators
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34(12): 33 – 45, 2023; Article No.: JAMMR.92716
PC1-PC5 had factor loadings of 0.810, 0.910, 0.833, 0.509, and 0.540 respectively and error
variances of 0.66, 0.83, 0.69, 0.26, and 0.29 respectively. These parameters are consistent
with the position that these are reliable indicators of the construct of physical comfort.

Figure 3: Measurement Model of Emotional Support

Table 4: Measurement Model Analysis of Emotional Support
Model Chi- χ²/df NFI TLI CFI RMSEA Variable Factor Error
Square(df), Loading VAR
Significance Estimates
Emotional (15df) 4.504 0.915 0.875 0.925 0.169 ES1 0.808 0.65
Support =67.559

ES2 0.873 0.76

ES3 0.862 0.74
ES4 0.822 0.68
ES5 0.861 0.74
The model was overidentified with five degrees of freedom. Guided by suggestions provided
in Hair (2006) who suggested the following indices to indicate acceptable fit GFI>0.90);
NFI>090; PNFI>0.60; RMSR<0.10; CFI>0.90; AGFI>0.80; RMSEA<0.08. As suggested by
Byrne (2006), parameter estimates, factor loading (Standardised regression weight) should
be greater than 0.5 and preferably above 0.7, while Brown (2010) suggested that completely
standardized factor loadings of 0.4 and above are commonly used to operationally define a
“salient” factor loading. Table 4 summarized the goodness of fit indices, the factor loading
estimates and the error variances. The results of the goodness of fit indices indicated
moderate fit to the data for one-factor model (chi-square (5df)=67.559, χ²/df=4.504,
RMSEA=0.169, CFI=0.923, NFI=0.998 and TLI=0.875). The indicators ES1-ES5 had factor
loadings of 0.808, 0.873, 0.862, 0.822, and 0.861 respectively and error variances of 0.65,
0.76, 0.74, 0.68, and 0.74 respectively.

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Figure 4 Structural model (linking the hypotheses)

This model, adopted the multiple-indicator measurement approach, using the reflective
indicators, reflective measurement model and recursive structural model. Therefore, the
relationship between constructs is specified after the transition from the measurement
model to the structural model.

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Table 5: Test of Hypotheses
S/N Stage Hypotheses Estimate Critical P-value Decision
(Beta value) Ratio
(C.R) < 0.05

1 TRF →PC There is no 0.838 5.225 0.001 Ho is

significant rejected
(Hypothesis 1) relationship
between
transformational
leadership and
physical comfort.
2 TRF →ES There is no 0.817 2.118 0.034 Ho is
(Hypothesis 2) significant rejected
relationship
between
transformational
leadership and
emotional support.

4. DISCUSSION
The overreaching aim of the study is to identify the relationship between transformational
leadership and patient-centered care (measured by physical comfort and emotional
support) in tertiary hospitals in Rivers State, Nigeria. Based on the Theory of Planned
Behavior (TPB) (Ajzen, 1991) and the quality-of-service features model (McCormack &
McCance, 2016), the study developed a framework to explore the potential relationship
between transformational leadership and patient-centered care in tertiary hospitals in
Rivers State, Nigeria.
The first specific objective was to evaluate the relationship between transformational
leadership and physical comfort. This objective was captured by a research question and
expressed under Ho:1. It was postulated in Ho:1 that there is no significant relationship
between transformational leadership and physical comfort. This theorising logic was not
supported. In other words, increase in transformational leadership is associated with
increase in physical comfort. This finding aligns with the findings of Page (2004) who found
that transformational leadership is critical for the implementation of effective management
that establishes a culture of patient safety. This finding is also in consonance with Houser
(2003) who found that empowering leadership is critically related to patient outcomes by
promoting greater nursing expertise through increased staff stability, and reduced turnout.
Furthermore, this finding is consistent with Janssen et al. (2004) who found that there is a
significant relationship between transformational leadership and additional effort,
perceived Also, this finding supports the theoretical assertion extracted from the theory of
planned behaviour which states that the evaluation of each outcome contributes to the
attitude in direct proportion to the person's subjective possibility that the behavior produces
the outcome in question (Guastello and jay, 2019).
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The next objective was to examine the relationship between transformational leadership and
emotional support and was captured by a research question and expressed under Ho:2. This
second hypothesis stated that there is no significant relationship between transformational
leadership and emotional support. The result of this study did not support the hypothesis.
The result shows that there is a positive and significant relationship between
transformational leadership and emotional support in tertiary hospitals in Rivers State,
Nigeria. This means that increase in transformational leadership is associated with increase
in emotional support. This finding agrees with Al-Mailam (2004) who found that
transformational leadership style is critical for high degrees of leadership effectiveness. This
finding is also in conformity with Stordeur and D'hoore (2002) who found that
transformational leadership characteristics significantly relate with efficiency and staff
maintenance. The finding of the study validates the theoretical assertion of the quality-of-
service features model (Hay wood farmer, 1997) which expresses that service organization
will achieve high quality, if they always meet the customer’s expectations and conceptions.
The application of this theory in healthcare settings have contributed to the coining of the
term ‘Person-centeredness’ and it is being used to describe a standard of care that ensures
that the patient/client is at the center of care delivery.
5. CONCLUSION
The main conclusion of this study is that leadership styles enhances patient-centered care
in tertiary hospitals, in Rivers State, Nigeria. Specifically, it is concluded that Management
commitment to transformational leadership significantly enhances the two measures of
patient-centered care (physical comfort and emotional support) in tertiary hospitals, in
Rivers State, Nigeria. This study pratically implies that Management of tertiary hospitals, in
Rivers State, Nigeria, ought to know how they can enhance patient-centered care through
the lens of transformational leadership style. Therefore, it is recommended that
Management of tertiary hospitals should increase the adoption of transformational
leadership. This can be accomplished by counselling and motivating others on what need to
be accomplished, specifying the importance of having a strong relationship and sense of
purpose, spending time teaching and coaching, displaying a sense of power and confidence,
articulating a compelling vision of the future and motivating others to follow.

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