Enhancing Nurses’ Well-Being: Exploring the Relationship between Transformational Leadership, Organizational Justice, and Quality of Nursing Work Life

Aim . Te study’s aim was to examine the relationship between transformational leadership, organizational justice


Introduction
Te World Health Organization (WHO) estimates that by 2030, the world will need nine million nurses and midwives to attain the goal of health and well-being [1].Within the healthcare industry, nurses hold a signifcant position as they are the frontline caregivers who have a profound impact on patient outcomes and overall healthcare quality [2].In this context, healthcare organizations require leaders who possess not only a position of authority but also the ability to inspire and guide their teams efectively.Te achievement of improved organizational practices in the feld of nursing relies on the combined eforts of leadership and staf collaboration.Transformational leadership plays a crucial role in this process, acting as a mediator and yielding favorable outcomes for all parties involved [3].
Transformational leadership is characterized by its capacity to inspire followers to embrace the organization's vision, goals, and strategies actively.Tis leadership style, marked by its inspirational and motivating nature, has a signifcant impact on the nursing turnover rate [4].Te implementation of transformational leadership concepts has the potential to impact various aspects of both the workforce and the company.Tese efects encompass the reduction of burnout, the enhancement of job satisfaction, the retention of nursing staf, and the improvement of overall productivity [5].As leaders, nurse managers are also essential in fostering a secure, empowering, and gratifying atmosphere for staf members and patients [4].
Transformational leaders tend to promote a fair and equitable work environment, fostering trust, respect, and the provision of adequate resources [6][7][8][9].Nurses working under transformational leaders perceive organizational justice, including distributive justice, procedural justice, and interactional justice, which positively afect their job satisfaction, commitment, and overall well-being [7,10,11].
Nurse managers bear the responsibility of maintaining patient safety, promoting quality of care, enhancing quality of work life, and managing the dynamics of change in health care [7].Te leadership/management style is a signifcant factor infuencing nursing job satisfaction and has a direct impact on nurses' quality of work life [12].
Quality of work life is a complex concept that encompasses a range of factors, including possibilities for professional growth, the efective application of talents and abilities, pay, the balance between work and personal life, and the overall state of well-being within the work setting [5].
Transformational leadership is essential to improve productivity at work and quality of life simultaneously.Worker happiness and a sense of justice inside the workplace are also connected to the quality of work life.Nurses' quality of work life and job happiness may improve if managers are fair in their dealings, use inspiring leadership techniques, and make fair decisions [13].Te consideration of leadership's efect on nurses' productivity and working-life quality is of signifcant importance.Developing a transformational nursing leadership style is a viable organizational approach to enhance nurse performance and foster improved patient care outcomes [12].Te transformational approach of leadership is widely acknowledged as a successful leadership style that may signifcantly infuence several aspects of an employee's professional life, such as career satisfaction, engagement, and performance [2,11,14,15].
Additionally, organizational justice, a critical aspect of workplace dynamics, has a documented association with nurses' health and well-being, as well as positive workrelated outcomes [16].Organizational justice pertains to the perceptions held by employees on the just and equitable treatment they receive within the organization.Tis concept incorporates various aspects such as equity, fairness, and social ties that are present in the workplace [17].Nurses who possess a perception of fairness and justice within their respective healthcare organizations are inclined to exhibit behaviors that surpass their prescribed job responsibilities [16,17].
Organizational justice has been found to have a signifcant impact on the quality of work life [18][19][20][21].High organizational justice improves work-related outcomes, health, and well-being among registered nurses environment [16,[22][23][24].On the other hand, low organizational justice is linked to undesired work-related outcomes and health problems [16,23,24].Nurses who perceive low organizational justice may experience dissatisfaction with their profession and organization, leading to a lower quality of work life.
Furthermore, previous studies have demonstrated a signifcant association between organizational justice in healthcare environments and the level of job satisfaction among nurses [20,25].Berthelsen et al., [26] have also demonstrated a positive correlation between the perception of organizational justice at the unit level and the reported quality of care by staf members.In light of the intricate nature of the present-day healthcare landscape, it is imperative for nurse leaders to accord utmost importance to the concept of organizational justice [16].
Nevertheless, the current body of literature mostly examines transformational leadership, organizational justice, and quality of work life as distinct concepts, failing to acknowledge the potential combined impact they may have on improving the well-being of nurses and the quality of healthcare.Te study aims to provide signifcant fndings that can help healthcare leaders, administrators, and policymakers implement strategies to enhance nurse well-being, justice practices within organizations, and overall quality of nursing life at the workplace.

Aim of the Study.
Te aim of this study is to investigate the relationship between transformational leadership, organizational justice, and the quality of work life in the nursing profession.

Te Teoretical
Framework.Te conceptual model employed in this study was founded upon a theoretical framework that has been constructed from the job demandsresources (JD-R) model (Figure 1).Te JD-R model provides a framework for examining the impact of job characteristics on employees' well-being [27,28].Job demands referred to the physical cognitive or emotional requirement of a job that can be perceived as stressful or challenging for employees.Tese demands can include high workload time pressure emotional labor and other factors that require efort and may drain employee energy.On the other hand, your job resources are the aspect of the work environment that can help employees to achieve their work goals [27,28].According to the job demands-resources model (JD-R), transformational leadership and organizational justice can be viewed as job resources that can enhance the quality of nursing work life by providing support, autonomy, and fairness.Transformational leadership is a leadership style characterized by the leader's ability to inspire and motivate their followers to achieve their higher level of performance and personal growth [29].Tis leadership approach has been widely studied and recognized as a key determinant of employee satisfaction, commitment, and overall organizational success [10,30].In the context of nursing, the transformational leadership style has been founded to positively infuence various aspects of nurses' work life and include job satisfaction, organizational commitment, and professional development [2,3,7,12,21,31].Terefore, the following hypothesis developed: H1.Higher levels of transformational leadership will be positively associated with improved quality of nursing work life.

Organizational Justice and Quality of Nursing Work
Life.Numerous studies examined the relationship between organizational justice and quality of work life.Tese studies consistently suggested that higher levels of organizational justice are associated with improved work-related outcomes.For instance, Arab and Atan [22] argued that perceived distributive, procedural, and interactional justice all contribute to employee job satisfaction and job performance.Berthelsen et al. [26] demonstrated that the shared perception of organizational justice climate was signifcantly associated with perceived quality of care and afective commitment to the organization.In the nursing context, the study of Dong et al. [17] revealed that perceived job characteristics and organizational justice can improve nursing care quality through work engagement.We can conclude that nurses are more likely to feel valued and motivated, leading to increased job satisfaction, commitment, and overall positive work outcomes.Terefore, the following hypothesis developed: H2: High perceptions of organizational justice will correlate with enhanced quality of nursing work life

Transformational Leadership and Organizational
Justice.Transformational leaders are more likely to be perceived as fair and just by their employees.Tis is because they are seen as role models who exhibit ethical behaviors, treat employees with respect, and involve them in the decision-making process.Te leaders that exhibit transformational leadership conduct in a manner that is regarded by their followers as respectful, fair, and aligned with moral and ethical principles might anticipate a higher level of organizational attachment from their followers as a suitable reaction to the provision of interactional justice [32].Te study of Deschamps et al. [33] demonstrated that transformational leaders have a positive impact on their employees' motivation through diferent aspects of organizational justice.Also, the mediation study of Gillet et al. [31] revealed that transformational leaders infuenced positively on nurses' perception of organizational justice.Terefore, the following hypothesis developed: H3.Higher levels of transformational leadership will be positively associated with increased perceptions of organizational justice among nurses Te proposed conceptual model of the research was developed to visually clarify the relationship between the study variables.Te circular shapes were employed to represent the key study variables, and arrows indicated the directional relationships, with plus (+) denoting positive associations.

Study Design and Setting.
Te present cross-sectional research was conducted at a general hospital that is associated with the Egyptian Ministry of Health institutions.Tis hospital serves a catchment area with an estimated population of over 300,000 individuals.Te hospital ofers a wide range of medical services including many disciplines such as internal medicine, obstetrics and gynecology, surgery, pediatrics, ophthalmology, orthopedics, dermatology, and psychiatry.In addition, the facility provides diagnostic services including laboratory testing, radiography, and ultrasound.Te healthcare system in Egypt is pluralistic, with public and private providers ofering diverse services.Te government ensures universal health coverage, while private services are accessible to those with fnancial means.Te study follows the STROBE reporting guidelines [34].

Participants.
Te study utilized a convenience sample strategy due to its practicality and ability to recruit the participants efciently.Te study included registered nurses who are experienced nurses with at least one year in their current nursing position, full-time employed, and directly involved in patient care.Nursing interns and nurses who held management positions or served as shift leaders were excluded from this study.Te Egyptian nursing syndicate Journal of Nursing Management categorizes registered nurses based on their level of education and qualifcations.Tese categories encompass nurses with technical education, comprising nurses holding a diploma or institute nursing degree (referred to as technical nurses), as well as those possessing a bachelor's degree and postgraduate degree (referred to as specialist nurses).Te researchers utilized the global transformational leadership scale created by Carless et al. [35] to assess the perception of transformational leadership exhibited by nurses' direct leaders/managers.Te scale comprises seven items designed to assess four dimensions: two items measure idealistic impact, two measure inspirational motivation, two items measure individual consideration, and one item measures intellectual stimulation and critical thinking.Te value of Cronbach's alpha found in this research was 0.87.

Data Collection
Te organizational justice scale was developed by Niehof and Moorman [36] to assess nurses' perceptions of fairness within healthcare organizations.Te scale consists of twenty items categorized into three primary dimensions of justice: (1) distributive justice, which encompasses fve items; (2) interactional justice, consisting of nine items; and (3) procedural justice, which includes six items.Te Cronbach's alpha coefcients for the constructs in this study were as follows: organizational justice (Cronbach α � 0.94), distributive justice (Cronbach α � 0.87), interactional justice (Cronbach α � 0.90), and procedural justice (Cronbach α � 0.75).
Te quality of nursing work-life scale was initially developed by Brooks [37] to evaluate nurses' subjective perception of the quality of life at their workplace.Te scale comprised a total of forty-two items, which were classifed into four distinct subscales: (1)  Te nurses were asked to indicate their degree of agreement with sixty-nine questionnaire items.Tey were given a 5-point Likert scale, ranging from one represented "strongly disagree" to fve represented "strongly agree." Te evaluation of the study variables was determined by calculating the average score of each variable, which was obtained by dividing the total score by the number of items within the corresponding scale and subscales.Te approach utilized in this study involved the conversion of original ratings into a standardized Likert scale, which encompassed a range from 1 to 5. Hence, scores falling within the range of 1-2.59 signify a low level of perception, while scores ranging from 2.60 to 3.39 suggest a moderate level of perception.On the other hand, scores falling within the range of 3.40-5.0signify a high level of perception [38].
Te researchers adhered to a translation and backtranslation methodology for the English version of the scales that aligned with established practices observed in previous studies [39][40][41][42].Te researchers translated the study scales from English to Arabic and compared the translated texts to generate an initial version.An English teacher translated the scales back into English, and a native English speaker reviewed it to ensure it matched the original version.A panel of fve specialists evaluated the Arabic version of the scales to assess readability, clarity, meaningfulness, and face validity.Te fnal version was validated after incorporating revisions suggested by the reviewers.Translating the scales into Arabic acknowledges participants' linguistic profciency in their native tongue, reduces language barriers, enhances cultural relevance, respects linguistic diversity, and improves data accuracy.Tis method aligns with research best practices and emphasizes the need for a careful translation process for validity and reliability.
Te scales included in our research, namely the global transformational leadership scale, organizational justice scale, and quality of nursing work-life scale, were subjected to a thorough evaluation of content validity following the principles outlined by Davis [43].Te content validity of all scales was found to be strong, with scores of 1.00, 0.97, and 0.98, respectively.Te subscales present in these instruments likewise demonstrated values over the threshold of 0.90, while the individual items had an item-content validity index that topped 0.80.Te obtained results provide confrmation of the meticulous construction and validation process of our instruments, confrming their pertinence and suitability for assessing the constructs of our study [43].Before data collection, the researchers conducted a pilot study that included 25 nurses to assess the research framework and methodologies and address any potential challenges.Te pilot study data were excluded from the total study population.Based on the recommendations provided by the pilot study sample and experts' input, the rating scale for assessing the quality of nursing work life was modifed from a six-point Likert scale to a fve-point Likert scale.Tis modifcation was implemented based on the belief that the fve-point Likert scale would ofer 4 Journal of Nursing Management enhanced clarity and facilitate more efective respondent comprehension and response.

Ethical Considerations.
Te participants were provided with information on the voluntary nature of their involvement, the assurance of anonymity in their replies, and the option to withdraw from the study at any point.Teir choice to participate did not afect their professional occupation.Participants provided verbal consent before distributing a questionnaire, and they further solidifed their consent by signing an informed consent form.Transformational leadership was added in the second step (independent variable) and organizational justice in the third step (independent variable).Te second hierarchical linear regression (model 2) was conducted to ascertain the factors that are linked to organizational justice (dependent variable).Te initial stage involved including demographic data to mitigate their infuence.Te inclusion of transformational leadership occurred during the second phase (independent variable).Te categorical variables were recoded as dummy variables (control variables).Before conducting hierarchical linear regression, the research variables underwent mean-centering before multiplication.Tis was carried out to mitigate the issue of multicollinearity throughout the analysis and uphold the assumption of independence of errors among the variables.Te possible presence of multicollinearity for the regression model was assessed through tolerance (model 1: 0.17-0.98;model 2: 0.17-0.96)and the variance infation factor (model 1: 1.03-6.02;model 2: 1.04-6.03),confrming that the basic requirements of regression analysis were satisfed.Statistical signifcance was set at an alpha level of 0.05 for inferential data analysis.

Results
Out of a total of 566 nurses, 527 nurses completed the survey resulting in a response rate of 93.1%.Te mean age of the nurses included in the study was 33.23 years, with a standard deviation of 7.18 years.Most of the nurses were female (96.2%), married (85.2%), and had a technical degree of education (67.9%).Te mean experience year of the nurses was 11.79, with a standard deviation of 7.95 (Table 1).
Positive relationships were observed between transformational leadership and organizational justice and its subscales.Tere is a positive correlation between transformational leadership and the quality of nursing work life and the various subscales.Tere was a favorable relationship between organizational justice and the quality of nursing work life and its subscales (Table 3).
Hierarchical regression model 1 explains 24.9% of the variance in organizational justice.Te strongest predictor of organizational justice was transformational leadership (β � 0.468, p < 0.001), followed by age (31-40 years) (β � −0.133, p � 0.021) and nursing categories (β � 0.112, p � 0.006).Tis indicates that technical nurses who perceived their leaders as transformational were likelier to report higher organizational justice levels.Also, nurses aged 31-40 years had a signifcant negative association with organizational justice, suggesting that they perceived lower levels of justice compared to those aged more than 40 years.Hierarchical regression model 2 explains 51.7% of the variance in the quality of nursing work life.Te highest predictor of quality of nursing work life was organizational justice (β � 0.451, p < 0.001), followed by transformational leadership (β � 0.350, p < 0.001).Tis means nurses who had their leader as transformational and experienced elevated levels of organizational justice were more likely to report a higher quality of nursing work life (Table 4).

Discussion
Tis study aimed to explore the relationship between transformational leadership, organizational justice, and quality of nurses' work life.Additionally, the study aimed to evaluate the variables under investigation.
Te study's fndings provided empirical support for hypotheses 1 and 2, demonstrating that transformational leadership and organizational justice emerge as substantial predictors of the quality of nursing work life.Tis underscores the pivotal role these factors play in shaping nurses' experiences and job satisfaction.Tese fndings may be due to diferent assumptions; frst, transformational leadership fosters a positive and supportive work environment where nurses feel valued and motivated.Tis enhances the overall quality of nurses' work life by promoting job satisfaction and engagement [2,12,23].Second, Journal of Nursing Management organizational justice enhances trust and respect among employees, as they believe that the organization treats them fairly [9].Trust and respect are vital components of a highquality work life, leading to stronger work relationships and job satisfaction [22].Tird, fostering a positive work environment and promoting perceptions of justice can contribute to the mitigation of burnout and turnover intentions among nurses.Consequently, this enhances the overall quality of the nursing work environment [24].
Te study aligns with Akar and Ustuner's [6] research, which found a positive correlation between teachers' perceptions of transformational leadership by school administrators and their work-life quality.Tis relationship was mediated by their perceptions of organizational support and justice.Te study conducted by Gillet et al. [31] revealed that transformational leadership directly afects the quality of work life for nurses and this efect is mediated by justice.In a study, Kasim and Aldarmaki [45] investigated the connection between justice, quality of work life, and turnover intention among police personnel in the United Arab Emirates.Teir fndings suggested that the quality of work life acts as a mediator in the relationship between justice and turnover intention.
Te study by Totawar and Nambudiri [13] discovered that organizational justice has a positive relationship with quality of work life and that this relationship was mediated by job satisfaction.Te study by Prameswari et al. [46] found that organizational justice and transformational leadership positively and signifcantly impact job satisfaction, which is a crucial aspect of the overall quality of nursing work life.Kamel et al. [47] observed a signifcant positive correlation between the quality of nursing work life, organizational justice, and citizenship behaviors.Moghimi et al. [19] examined the correlation between organizational justice and quality of work life in public organizations in Qom Province, Iran.Te study revealed a positive association between distributive, procedural, and interactional justice, and quality of work life.
Te study's fndings support the cognitive evaluation theory, which suggests that transformational leadership promotes intrinsic motivation in nurses by meeting their needs for autonomy, competence, and relatedness [48].Transformational leaders empower nurses by granting them autonomy in decision-making, fostering professional growth opportunities, and creating a supportive work environment.Tese studies have shown that nurses' intrinsic motivation and job satisfaction are improved, leading to a higher quality of work life [12,19,49].
Te study's results supported the third hypothesis, revealing a favorable link between transformational leadership and organizational justice, which is consistent with previous research conducted in numerous settings and nations [10,30,31,33,[50][51][52]. Transformational leaders tend to advocate for fairness and transparency and encourage participative decision-making, which are essential components of organizational justice [8].When nurses perceive their leaders as transformational, they are more likely to feel that decisions are made fairly and that their voices are heard, leading to a higher level of organizational justice perception [31].Transformational leadership behaviors of nurse managers, such as inspiring, stimulating, considering, and infuencing their staf nurses, have been associated with positive outcomes for nurses, patients, and organizations.Te results involve diverse aspects including favorable work settings, employee behaviors, fairness in the workplace, safety culture for patients, and contentment with the job [11,15,53,54].
Te study found that nurses demonstrated a high perception of transformational leadership, suggesting the presence of positive and inspiring leadership behaviors in their work environment.Furthermore, the participants' perception of justice was at a moderate level.Tis suggests that there exists an ascertain level of fairness and equity within the workplace, but there may be areas that need to be improved.Additionally, the study showed that nursing work life exhibited a moderate quality from nurses' perspectives.Tese fndings indicate that nurses' work conditions, job satisfaction, and well-being were moderately satisfactory indicating potential for improvement in their work-related experiences.Tese fndings indicate that nurses' work conditions, job satisfaction, and well-being are moderately satisfactory, indicating potential for improvement in their   work-related experiences.Tese fndings align with prior studies conducted by Gillet et al. [31]; Sürücü [52]; Akdemir [50]; and Khan et al. [51], which reported high transformational leadership perceptions between nurses and other participants.

Journal of Nursing Management
Regarding organizational justice, the study by Sürücü [52] aligns with our fndings, indicating moderate levels of organizational justice.In contrast, Gillet et al. [31], Moghimi et al. [19], and Yasir et al. [30] reported divergent fndings, indicating that nurses exhibited low levels of justice perception and experienced an unfavorable quality of work life.Te literature presents diverse fndings regarding the quality of nursing work life.Kamel et al. [47] observed a high level of work-life quality and organizational justice.Conversely, Akar and Ustuner [6] discovered a moderate work-life quality and organizational justice level.

Limitations of the Study.
Tis study had some limitations.First, the utilization of a cross-sectional design in this study presents limitations in establishing causal relationships between variables.Second, the utilization of convenience sampling in this research may potentially add selection bias and restrict the ability to generalize results to a broader population of nurses.Finally, it is crucial to recognize that the study was carried out solely inside the confnes of a singular general hospital, which may potentially restrict the generalizability of the fndings to alternative healthcare settings.

Further Research.
In the light of limitations mentioned previously, there are several avenues for further research that can enhance the depth and the breadth of our understanding in this area.Future research should consider employing longitudinal or experimental designs to better establish causal relationships between the variables of interest.Furthermore, conducting an inquiry into the fundamental mechanisms and potential moderators of these associations can ofer a more profound comprehension of how to optimize the nursing work environment and boost the quality of patient care.Also, the forthcoming studies should utilize random sampling procedures, such as simple random sampling or stratifed random sampling, and include multiple healthcare settings to overcome selection bias and restriction of generalizability of results to a broader population of nurses in the other healthcare settings.

Conclusions
Te study discovered that nurses had a high perception of transformational leadership and moderate levels of organizational justice and quality of nursing work life.Moreover, a positive correlation existed between transformational leadership and organizational justice, indicating that these factors signifcantly improve the quality of work life for nurses.Tose who view their leaders as transformational and work in a fair organizational climate are more likely to report higher levels of quality of work life.

Implications of the Study
Hospital administrators should invest in developing transformational leadership training programs for nurse leaders to promote a fair and supportive work environment.Additionally, eforts to improve organizational justice and fairness in resource allocation can lead to enhanced nurse well-being and overall job satisfaction.Terefore, nurse managers can enhance the work environment for nurses and yield benefts for both employees and the organization by prioritizing these factors.

Figure 1 :
Figure 1: Te proposed conceptual model of the study.

Table 2 :
Descriptive statistics of the study variables (N � 527).

Table 3 :
Correlation matrix among the study variables (N �

Table 4 :
Predictors of organizational justice and quality of nursing work life.