Based on transformational leadership theory and the empirical evidence described above, transformational leadership development is expected to improve nurses’ workplace experiences by strengthening leadership practices that support communication, collaboration, professional development, and a favourable work environment.^5–7 Accordingly, the following hypothesis was formulated:

This quasi-experimental study employed a pre-test and post-test control group design to evaluate the effectiveness of a structured transformational leadership program delivered to nurse managers on staff nurses’ job satisfaction and perceptions of the work environment. The study was conducted in seven government-operated Ministry of Health primary healthcare centers (PHCs) in Medina, Saudi Arabia. The participating PHCs were Al-Hijrah Health Center, Wa’irah Health Center, Al-Safiyyah Health Center, the Health Surveillance Center at Prince Mohammed bin Abdulaziz International Airport, Al-Daithah Health Center, Bab Jibreel Health Center, and Al-Salsalah Health Center. Four PHCs comprised the intervention group and three comprised the control group. The intervention was delivered to nurse managers in the intervention PHCs, while outcomes were assessed among staff nurses working under their supervision.

The target population comprised registered nurses employed at the seven participating PHCs, with a total population of 142 nurses. The required sample size was calculated using a 95% confidence level and a 5% margin of error for the finite study population, resulting in a required sample of 104 nurses. Convenience non-probability sampling was used to recruit eligible participants until the required sample size was achieved. A total of 104 nurses were included in the study, with 52 nurses in the intervention group and 52 in the control group. The transformational leadership programme was delivered to 52 nurse managers in the intervention PHCs. All participants completed both the pre-intervention and post-intervention assessments and were included in the final analysis. Eligible participants were registered nurses employed at one of the participating PHCs who provided written informed consent. Non-nursing staff and nurses who declined to provide informed consent were excluded.

The 104 nurses were recruited from seven participating PHCs. The intervention group comprised nurses from Al-Hijrah (n = 16), Wairah (n = 11), Al-Safiyyah (n = 13), and the Health Surveillance Center (n = 12), while the control group comprised nurses from Al-Daithah (n = 13), Bab Jibreel (n = 14), and Al-Salsalah (n = 15). The nurse managers who received the intervention were not included in the outcome analysis, and their individual demographic and professional characteristics were not recorded in the available study dataset. Therefore, manager-level characteristics could not be reported retrospectively. The number of nurses supervised by each nurse manager could not be determined retrospectively because individual nurse–manager linkages were not recorded in the available study records.

The intervention group comprised four PHCs: Al-Hijrah Health Center, Wa’irah Health Center, Al-Safiyyah Health Center, and the Health Surveillance Center at Prince Mohammed bin Abdulaziz International Airport. The control group comprised three PHCs: Al-Daithah Health Center, Bab Jibreel Health Center, and Al-Salsalah Health Center. Nurse managers in the intervention PHCs received the transformational leadership program, whereas nurse managers in the control PHCs continued their routine leadership practices during the study period.

The transformational leadership program was developed to strengthen nurse managers’ leadership competencies and their ability to foster supportive workplace relationships, effective communication, team motivation, and a positive organizational climate. The program was based on the four core dimensions of transformational leadership: idealised influence, inspirational motivation, intellectual stimulation, and individualized consideration.

The program was delivered over two weeks and comprised five training days, with two training days during the first week and three during the second week. Each training session lasted approximately three hours. The program combined interactive lectures, facilitated group discussions, case-based learning, role-playing exercises, leadership simulations, and practical problem-solving activities. The training covered transformational leadership principles, effective communication, team motivation, conflict management, ethical leadership, decision-making, and strategies for improving workplace collaboration. Practical activities enabled nurse managers to apply transformational leadership behaviours to realistic situations encountered in primary healthcare practice.

Program evaluation included a pre-training assessment before the intervention and a post-training assessment at program completion. Participants also completed a program evaluation form and received certificates of completion. Structured observational checklists were used during practical leadership exercises to assess leadership behaviours. Following completion of the program, weekly unannounced observational visits were conducted for six months to monitor the application of transformational leadership behaviours in routine managerial practice.

The primary study outcomes were nurses’ job satisfaction and perceptions of the work environment. Outcomes were assessed using standardised self-administered questionnaires administered before the intervention and after completion of the two-week program.

Job satisfaction was assessed using a 20-item questionnaire based on the short-form Minnesota Satisfaction Questionnaire (MSQ). The questionnaire used in this study comprised 12 items assessing intrinsic job satisfaction and 8 items assessing extrinsic job satisfaction. Each item was rated on a five-point Likert scale ranging from 1 (very dissatisfied) to 5 (very satisfied). Scores for the intrinsic job satisfaction domain were calculated by summing the 12 corresponding items, resulting in a possible score range of 12–60. Scores for the extrinsic job satisfaction domain were calculated by summing the 8 corresponding items, resulting in a possible score range of 8–40. Overall job satisfaction was calculated by summing all 20 items, resulting in a possible score range of 20–100. Higher scores indicated greater job satisfaction. The questionnaire used in this study is provided as extended data.

Work environment was assessed using 11 items adapted from the Areas of Worklife Survey (AWS), covering six domains: workload, control, reward, community, fairness, and values. Each item was rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The work environment score was calculated by summing the scores of the 11 items, resulting in a possible total score ranging from 11 to 55, with higher scores indicating more favourable perceptions of the work environment. The full set of items used in the study is provided as extended data.

The questionnaire was pilot-tested among 25 nurses at Al-Hijrah PHC before the main study to assess the clarity and comprehensibility of the items. Content validity was assessed by a panel of experts using the item-level content validity index (I-CVI). The I-CVI values ranged from 0.83 to 0.94 across the questionnaire items, indicating acceptable content validity. Internal consistency was assessed using Cronbach’s alpha, with a coefficient greater than 0.70 considered acceptable. The MSQ was selected because of its established validity and reliability and its previous use in healthcare settings, including Saudi Arabia.

Before data collection, eligible nurses were informed about the study objectives, procedures, voluntary nature of participation, and confidentiality of the information collected. The study procedures and questionnaire administration were conducted online. Eligible nurses received the study information and an electronic informed consent form before completing the online questionnaire. Only nurses who provided informed consent were enrolled in the study. Baseline questionnaires were completed online by nurses in both intervention and control PHCs before nurse managers in the intervention group participated in the transformational leadership program.

Following completion of the two-week intervention, the same outcome measures were administered online to assess post-intervention changes in nurses’ job satisfaction and perceptions of the work environment. The same standardized online questionnaire administration procedures were used for participants from all participating PHCs.

Weekly unannounced observational visits were subsequently conducted for six months to monitor the implementation of transformational leadership behaviours among nurse managers in the intervention group. These observations were used to monitor intervention implementation and were not the primary assessment of nurses’ job satisfaction or work environment.

Several procedures were used to promote consistency in intervention implementation and outcome assessment. The same outcome measures were administered before and after the intervention, and standardized questionnaire administration procedures were applied across participating PHCs. Participation was voluntary, written informed consent was obtained, and confidentiality of participant responses was maintained. The control group continued routine leadership practices during the study period, providing a comparison condition for assessing changes over time. Weekly unannounced observational visits were used to monitor the implementation of the intervention following training.

Data were analyzed using IBM SPSS Statistics version 20.0. Descriptive statistics were used to summarise participant characteristics and study variables. Continuous variables were presented as means and standard deviations, while categorical variables were presented as frequencies and percentages.

Independent-samples t-tests were used to compare continuous study outcomes between the intervention and control groups at baseline. Paired-samples t-tests were used to assess changes in overall job satisfaction, intrinsic job satisfaction, extrinsic job satisfaction, and work environment from pre-intervention to post-intervention within each group. Cohen’s d was calculated to quantify the magnitude of within-group changes.

Because significant baseline differences were observed between the intervention and control groups for overall, intrinsic, and extrinsic job satisfaction, as well as work environment, ANCOVA was used as the primary comparative analysis to compare post-intervention outcomes between groups while adjusting for the corresponding baseline scores. Before conducting ANCOVA, the assumption of homogeneity of regression slopes was assessed by testing the interaction between group and the corresponding baseline outcome score. The assumption was considered satisfied when the interaction term was not statistically significant (p > 0.05). Adjusted means, F statistics, p values, and partial eta squared (partial η²) were reported as measures of intervention effect and effect size.

Pearson correlation analysis was conducted to examine the relationships among intrinsic job satisfaction, extrinsic job satisfaction, work environment, and overall job satisfaction. Associations between participant characteristics and overall job satisfaction were examined using independent-samples t-tests for categorical variables with two groups and one-way analysis of variance (ANOVA) for variables with more than two groups. All statistical tests were two-sided, and p < 0.05 was considered statistically significant.

A total of 104 registered nurses participated in the study, comprising 52 nurses in the intervention group and 52 in the control group. All participants completed both the pre-intervention and post-intervention assessments and were included in the final analysis. Participant characteristics are presented in Table 1.

The largest proportion of participants was aged 36–45 years (31/104, 29.8%), followed by those aged 26–35 years (27/104, 26.0%). More than half of the participants were female (57/104, 54.8%), Saudi nationals (96/104, 92.3%), and married (52/104, 50.0%). Regarding educational attainment, 50 participants (48.1%) held a bachelor’s degree and 39 (37.5%) held a diploma. Professional experience varied, with 24 participants (23.1%) reporting more than 20 years of experience.

Baseline study outcomes are presented in Table 2. Significant differences were observed between the intervention and control groups for all four study outcomes. The intervention group had higher baseline overall job satisfaction than the control group (56.40 ± 13.79 vs. 49.50 ± 10.35; t = 2.887, p = 0.005). Intrinsic job satisfaction was also higher in the intervention group (32.60 ± 9.34 vs. 28.44 ± 6.67; t = 2.611, p = 0.010), as was extrinsic job satisfaction (23.81 ± 5.39 vs. 21.06 ± 4.62; t = 2.791, p = 0.006). Work environment scores were likewise higher in the intervention group than in the control group (36.48 ± 8.47 vs. 32.33 ± 9.02; t = 2.421, p = 0.017). These baseline differences were taken into account in the subsequent ANCOVA analyses.

Changes in study outcomes from pre-intervention to post-intervention are presented in Table 3. In the intervention group, significant improvements were observed in all four outcomes. Intrinsic job satisfaction increased from 32.60 ± 9.34 at baseline to 57.23 ± 1.72 after the intervention (mean difference = 24.63; t = −19.934, p < 0.001; Cohen’s d = 2.764). Extrinsic job satisfaction increased from 23.81 ± 5.39 to 38.06 ± 1.18 (mean difference = 14.25; t = −18.837, p < 0.001; Cohen’s d = 2.612).

Work environment scores increased from 36.48 ± 8.47 to 52.63 ± 1.72 (mean difference = 16.15; t = −13.779, p < 0.001; Cohen’s d = 1.911). Overall job satisfaction increased from 56.40 ± 13.79 to 95.29 ± 2.46 (mean difference = 38.88; t = −20.719, p < 0.001; Cohen’s d = 2.873). In the control group, no statistically significant changes were observed in intrinsic job satisfaction (p = 0.689), extrinsic job satisfaction (p = 0.823), work environment (p = 0.911), or overall job satisfaction (p = 0.904). Effect sizes were negligible across all four outcomes.

Because significant baseline differences were observed for all four study outcomes, ANCOVA was used to compare post-intervention outcomes between the intervention and control groups after adjustment for baseline scores. The assumption of homogeneity of regression slopes was met for all outcomes. The group-by-baseline interaction was not statistically significant for overall job satisfaction (F = 0.948, p = 0.333), intrinsic job satisfaction (F = 2.931, p = 0.090), extrinsic job satisfaction (F = 0.200, p = 0.656), or work environment (F = 0.569, p = 0.452). The results are presented in Table 4. After adjustment for baseline scores, the intervention group had significantly higher post-intervention scores than the control group for overall job satisfaction, intrinsic job satisfaction, extrinsic job satisfaction, and work environment (all p < 0.001).

The adjusted mean for overall job satisfaction was 95.170 in the intervention group and 48.882 in the control group, corresponding to an adjusted mean difference of 46.288 (95% CI: 42.96–49.62; F = 759.851, p < 0.001, partial η² = 0.883). For intrinsic job satisfaction, the adjusted mean difference was 29.327 (95% CI: 27.50–31.15; F = 1016.011, p < 0.001, partial η² = 0.910). For extrinsic job satisfaction, the adjusted mean difference was 16.583 (95% CI: 14.39–18.78; F = 224.017, p < 0.001, partial η² = 0.689). For work environment, the adjusted mean difference was 19.826 (95% CI: 17.55–22.10; F = 298.502, p < 0.001, partial η² = 0.747).

Pearson correlation coefficients are presented in Table 5. Significant positive correlations were observed among all study variables (all p < 0.001). Overall job satisfaction demonstrated a strong positive correlation with intrinsic job satisfaction (r = 0.959), extrinsic job satisfaction (r = 0.891), and work environment (r = 0.801). Intrinsic job satisfaction was also positively correlated with extrinsic job satisfaction (r = 0.726) and work environment (r = 0.750). Extrinsic job satisfaction was positively correlated with work environment (r = 0.742).

Associations between selected participant characteristics and overall job satisfaction are presented in Table 6. Educational level was significantly associated with overall job satisfaction (F = 12.39, p < 0.001). No statistically significant associations were observed for gender (t = −1.217, p = 0.227), age (F = 1.38, p = 0.246), or professional experience (F = 2.04, p = 0.094).

This study has several strengths. First, the quasi-experimental pre-test and post-test control group design allowed changes over time to be examined in both intervention and control groups. Second, the study evaluated both job satisfaction and work environment, providing a broader assessment of nurses’ workplace outcomes than studies examining a single outcome. Third, baseline differences between groups were explicitly assessed and statistically addressed using ANCOVA. Fourth, the intervention was structured, delivered over a defined two-week period, and included multiple educational approaches rather than relying solely on didactic instruction. The subsequent observational monitoring of leadership behaviours over six months also provided an additional mechanism for assessing implementation of the program.

Several limitations should nevertheless be considered. First, the study was conducted in PHCs within a single geographic region of Saudi Arabia, which may limit the transferability of the findings to other regions, healthcare organizations, or countries. Second, the study used convenience non-probability sampling and the participating PHCs were not randomly allocated to intervention and control conditions. Consequently, selection bias and residual confounding cannot be excluded, particularly given the significant baseline differences observed across all four outcomes. Although ANCOVA was used to adjust for baseline scores, statistical adjustment cannot fully substitute for random allocation.

Third, the intervention was delivered to nurse managers at the PHC level, whereas the primary outcomes were measured among individual staff nurses. Thus, participants were situated within organizational and managerial clusters. The present analyses did not explicitly model clustering at the PHC or nurse-manager level, which may affect the precision of standard errors and statistical significance. Future studies should consider cluster-randomized designs or multilevel analytical approaches when the intervention is delivered at the managerial or facility level.

Fourth, the primary outcomes were based on self-reported questionnaires and may therefore have been influenced by response or social desirability bias. Blinding participants to intervention status was also not feasible given the nature of the leadership program. Finally, although observational follow-up of leadership behaviours continued for six months, the primary nurse outcomes were assessed immediately following the intervention. Therefore, the study cannot determine whether the observed improvements in job satisfaction and work environment were sustained over the longer term. In addition, the study did not assess potential mechanisms through which transformational leadership may influence nurses’ job satisfaction or work environment. Therefore, the findings do not establish specific causal pathways underlying the observed intervention effects.

The findings have practical implications for nursing management and primary healthcare organizations. Structured transformational leadership development may be incorporated into professional development programs for nurse managers, particularly in settings undergoing organizational or health-system transformation. Rather than focusing exclusively on clinical competencies, leadership development can include communication, staff motivation, conflict management, ethical decision-making, teamwork, professional development, and individualized support for nurses.

For healthcare organizations in Saudi Arabia, such programs may complement broader workforce and quality-improvement initiatives under Saudi Vision 2030. However, leadership training should not be considered a substitute for addressing structural determinants of nurses’ work experiences, such as staffing, workload, resources, remuneration, and organizational policies. Leadership development is more likely to be effective when supported by an organizational environment that enables nurse managers to apply the behaviours acquired through training.

Future studies should use larger samples across multiple regions and healthcare organizations in Saudi Arabia to improve generalisability. Randomized or cluster-randomized designs would provide stronger evidence regarding the causal effects of transformational leadership programs. Because the intervention was implemented at the nurse-manager or PHC level, future studies should also use multilevel analytical approaches that account for clustering of nurses within managers and healthcare facilities.

Longer follow-up periods are needed to determine whether improvements in job satisfaction and work environment are sustained beyond the immediate post-intervention period. Future research could also examine potential mechanisms through which transformational leadership affects nurses’ outcomes, including psychological empowerment, work engagement, organizational commitment, perceived organizational support, and burnout. Qualitative research could further explore how nurses experience changes in managerial behaviours following leadership development programs and which components of the intervention are most influential.

The authors would like to express their sincere gratitude to Lincoln University College, Malaysia, for its academic support throughout this study. The authors also extend their appreciation to the management and staff of the participating Primary Healthcare Centres in Medina, Saudi Arabia, for facilitating the implementation of this research and to all nurses who generously participated in the study.

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