Transformational Leadership, Self-Efficacy, and Job Performance in Chinese Tertiary Hospital Nurses: A Cross-Sectional Structural Equation Model Study

Transformational Leadership, Self-Efficacy, and Job Performance in Chinese Tertiary Hospital Nurses: A Cross-Sectional Structural Equation Model Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Transformational Leadership, Self-Efficacy, and Job Performance in Chinese Tertiary Hospital Nurses: A Cross-Sectional Structural Equation Model Study Yuan Jiang, Minghao Kong Degree This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7007454/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Nurse job performance is critical to healthcare quality, particularly in high-demand, hierarchical systems such as tertiary hospitals in China. While transformational leadership and self-efficacy are known to influence performance, their interaction remains underexplored in culturally structured healthcare contexts. Purpose: This study investigates how transformational leadership relates to nurse job performance, with self-efficacy examined as a mediating mechanism. The model is grounded in Bandura’s social cognitive theory and the Job Demands–Resources (JD-R) model. Methods: A cross-sectional survey was conducted with 460 registered nurses from three tertiary Grade-A hospitals in Shanghai, selected via stratified random sampling. Self-reported data were collected using validated instruments: the Multifactor Leadership Questionnaire (MLQ), the Nursing Profession Self-Efficacy Scale (NPSES2), and the Nurse Job Performance Scale. Structural equation modeling (SEM) and bootstrapping were used to test direct and indirect effects. Results: Transformational leadership was positively associated with both nurse self-efficacy (β = 0.33, p < .001) and job performance (β = 0.18, p < .001). Self-efficacy was the primary predictor of job performance (β = 0.47, p < .001) and partially mediated the leadership–performance relationship, accounting for 46.3% of the total effect. Conclusion: These findings support a dual-pathway model in which transformational leadership enhances performance both directly and through psychological empowerment. The results offer practical insights for leadership development and underscore the importance of fostering self-efficacy in demanding, hierarchical healthcare systems. Future research ought to explore longitudinal designs and cultural moderators to extend generalizability. Health sciences/Health care Health sciences/Health occupations Biological sciences/Psychology Social science/Psychology Transformational leadership Nurse self-efficacy Job performance Structural equation modeling JD-R model China Healthcare leadership Figures Figure 1 Figure 2 1. Introduction In an era of increasingly complex patient needs, workforce shortages, and rising healthcare demands, the performance of nurses has emerged as a critical determinant of care quality and system efficiency(Aung Po et al., 2024 ). Nurses represent the largest group of frontline healthcare professionals and are responsible not only for clinical procedures but also for coordination, advocacy, and patient-centered decision-making(Nguyen et al., 2020 ). As health systems continue to evolve under pressure, ensuring high levels of nurse performance has become a central concern for healthcare institutions worldwide(Al-Ajarmeh et al., 2022 ; Krijgsheld et al., 2022 ). Despite its recognized importance, nurse job performance is subject to a range of organizational and psychological influences(Simanjuntak et al., 2021 ), particularly in tertiary hospitals where clinical workloads are heavy and administrative structures are rigid(Hao et al., 2023 ; Kumar & Bardhan, 2020 ). In China, tertiary Grade-A hospitals serve as the backbone of urban healthcare delivery(Li & Zhao, 2024 ; Y. Li et al., 2025 ). These institutions are characterized by hierarchical structures, resource concentration, and growing expectations for quality assurance, making them ideal but challenging environments in which to examine factors that influence nurse performance(Chen et al., 2024 ; Fu et al., 2025 ). A key concern in such contexts is how leadership and psychological resources interact to shape performance outcomes(Alsadaan et al., 2023 ). Transformational leadership has garnered growing attention in healthcare literature as a leadership style capable of motivating, empowering, and psychologically supporting staff(Niinihuhta et al., 2022 ; Ystaas et al., 2023 ). Defined by qualities such as inspirational motivation, individualized consideration, and intellectual stimulation, transformational leadership is associated with improved staff engagement, innovation, and resilience(Khan et al., 2022 ). However, the mechanisms through which transformational leadership affects nurse performance remain underexplored, especially in cultural contexts where deference to authority, formal hierarchy, and limited autonomy may constrain leadership impact(Hsiu-Ying et al., 2022 ). Understanding how transformational leadership operates within such constraints is vital for theory development and practical implementation(Broome, 2024 ). One potential pathway linking leadership to performance lies in self-efficacy—nurses’ belief in their ability to handle job-specific tasks effectively(Kim et al., 2022 ). According to Bandura’s social cognitive theory, self-efficacy serves as a core determinant of behavioral motivation, decision-making, and persistence under pressure(Bandura, 1991 ). In parallel, the Job Demands–Resources (JD-R) model identifies self-efficacy as a psychological resource that buffers job stressors and facilitates performance(Rhee et al., 2017 ). These two frameworks, when integrated, provide a robust basis for exploring how transformational leadership could affect performance through psychological empowerment mechanisms(Katou et al., 2022 ). Yet few studies have combined these theories to empirically test their synergy, particularly in high-demand and high-structure healthcare environments(Kaiser et al., 2020 ; Romero-Carazas et al., 2024 ). In addition, research on these constructs has largely focused on Western settings(Broome, 2024 ; Lin et al., 2015 ). While some studies have examined transformational leadership in Chinese nursing contexts, few have empirically explored how leadership behaviors translate into perceived self-efficacy and subsequent performance within the unique cultural and institutional constraints of Chinese tertiary hospitals(Sun et al., 2017 ; Xie et al., 2020 ). Elements such as power distance, collectivist norms, and bureaucratic coordination may not only shape how leadership is enacted but also influence how it is interpreted and internalized by staff(Li et al., 2019 ). These contextual dynamics are frequently overlooked in models derived from Western organizational psychology(Bui et al., 2017 ; Erez, 2011 ). Therefore, this study aims to examine the interrelationships between transformational leadership, nurse self-efficacy, and job performance among nurses working in tertiary hospitals in China. Drawing from Bandura’s social cognitive theory and the JD-R model, we test a mediation model in which nurse self-efficacy partially mediates the relationship between transformational leadership and nurse job performance(Cabrera-Aguilar et al., 2023 ). By integrating two theoretical perspectives and situating the study in a culturally specific healthcare context, this research contributes to the understanding of psychological mechanisms through which leadership could affect performance, and offers practical insights for nursing leadership development in high-intensity, hierarchical environments(Ying et al., 2021 ). 2. Literature Review and Theoretical Framework 2.1 Theoretical Foundations This study is grounded in two complementary theoretical frameworks: Bandura’s social cognitive theory and the Job Demands–Resources (JD-R) model. Bandura ( 1991 )emphasizes the role of self-efficacy—individuals’ beliefs in their capabilities to perform specific tasks—as a critical determinant of motivation, resilience, and performance. In nursing contexts, self-efficacy is associated with improved decision-making, persistence under stress, and confidence in clinical execution(AL Btoush et al., 2025 ; Lee & Ko, 2010 ). The JD-R model(Demerouti et al., 2001 ), on the other hand, conceptualizes employee well-being and performance as functions of the balance between job demands and job resources. Among the most powerful job resources are supportive leadership behaviors, which can reduce strain and bolster psychological resources such as self-efficacy(Tummers & Bakker, 2021 ). The model also accommodates structural and organizational influences, making it particularly suitable for analyzing high-stress, high-intensity workplaces such as tertiary hospitals(Mazzetti et al., 2024 ). By integrating these two frameworks, we propose that transformational leadership—a form of leadership rich in vision, mentorship, and psychological support—serves as a contextual job resource that enhances nurses’ self-efficacy, which in turn promotes job performance(Lai et al., 2020 ; Wu et al., 2025 ). This integration enables a multilevel understanding of both psychological (self-belief) and structural (leadership) factors shaping performance(Orlowska & Laguna, 2023 ). 2.2 Transformational Leadership in Nursing Contexts Transformational leadership is defined by four core dimensions: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration(Bass & Riggio, 2006 ). These qualities allow leaders to inspire shared goals, encourage staff innovation, and provide personalized support, which are especially relevant in complex healthcare environments(Brewer et al., 2016 ; Moon et al., 2019 ). Prior studies have shown that transformational leadership enhances nurse performance through multiple pathways—including empowerment, emotional support, and communication(Alwali & Alwali, 2022 ). However, the effects may vary depending on contextual features such as hierarchical structure and cultural norms(Hasan et al., 2023 ). In Chinese tertiary hospitals, where vertical authority structures prevail and autonomy may be constrained, transformational leadership may play an even more pivotal role in enhancing staff psychological readiness and motivation(Chu et al., 2021 ). 2.3 Nurse Self-Efficacy Self-efficacy refers to a nurse’s confidence in handling job-specific demands, including patient care, interprofessional communication, and clinical judgment(Mehralian et al., 2023 ). Bandura’s theory posits that individuals with high self-efficacy are more likely to approach difficult tasks as challenges to be mastered rather than threats to be avoided(Bandura, 1991 ). The JD-R model similarly identifies self-efficacy as a core psychological resource that buffers stress and facilitates job effectiveness(Demerouti et al., 2001 ). Recent studies suggest that nurse self-efficacy correlates positively with job satisfaction, teamwork, and adaptive coping(Kallerhult Hermansson et al., 2024 ). Despite its central role, few studies have examined how organizational factors—particularly leadership—can cultivate self-efficacy within culturally structured systems such as Chinese hospitals(J. Li et al., 2025 ). 2.4 Nurse Job Performance Nurse job performance encompasses technical skills, interpersonal coordination, work engagement, and the quality of patient care delivered(Sarıköse & Göktepe, 2022 ). It reflects not only clinical competence but also the ability to manage complex workloads, adhere to safety standards, and collaborate across units(Al-Ajarmeh et al., 2022 ). Given China’s increasing healthcare demands and workforce pressure, understanding predictors of nurse performance has become a strategic imperative(Zhang et al., 2021 ). Empirical evidence shows that job performance is positively influenced by psychological empowerment, professional identity, and leadership quality(Al Otaibi et al., 2023 ). However, most studies focus on direct effects, and few have explored psychological mediation mechanisms such as self-efficacy within hierarchical systems(Wang et al., 2021 ). The present study addresses this gap. 2.5 Hypothesis Development Based on the above theoretical foundation and empirical insights, we propose the following hypotheses: H1: Transformational leadership is positively associated with nurse self-efficacy. Rationale: Transformational leaders provide emotional support, mentoring, and clear expectations, which facilitate psychological confidence(Wu et al., 2025 ). H2: Nurse self-efficacy is positively associated with job performance. Rationale: High self-efficacy promotes persistence, proactive behavior, and confidence in decision-making, which contribute to higher performance(Kurniawan et al., 2019 ). H3: Transformational leadership is positively associated with job performance. Rationale: Leaders who clarify goals, provide feedback, and encourage innovation can improve nurse effectiveness through both motivational and procedural pathways(Boamah et al., 2018 ; Gebreheat et al., 2023 ). H4: Nurse self-efficacy partially mediates the relationship between transformational leadership and job performance. Rationale: Leadership influences job performance both directly and indirectly by enhancing nurses’ belief in their professional capability(Djourova et al., 2020 ). 2.6 Conceptual Model The conceptual model guiding this study is illustrated in Fig. 1 . It reflects the hypothesized pathways between transformational leadership, nurse self-efficacy, and job performance, integrating cognitive and organizational dimensions. 3. Methods 3.1 Research Design This study employed a quantitative, cross-sectional research design to examine the relationships between transformational leadership, nurse self-efficacy, and job performance. A structured online questionnaire was used to collect self-reported data from a sample of registered nurses. The design was guided by theoretical assumptions derived from social cognitive theory and the Job Demands–Resources (JD-R) model, and was appropriate for testing the hypothesized mediation model using structural equation modeling (SEM)(Bandura, 2001 ; Demerouti et al., 2001 ; Kline, 2023 ). 3.2 Participants and Sampling A stratified random sampling method was used to recruit participants from three tertiary Grade-A general hospitals located in different districts of Shanghai, China(Creswell & Creswell, 2017 ). These hospitals were selected to represent a range of institutional contexts, including a central urban district, a mixed-use industrial-residential zone, and an emerging economic development area(You et al., 2013 ). Within each hospital, lists of eligible clinical nurses were obtained from the nursing administration. Registered nurses were randomly selected using computer-generated random numbers (e.g., the RAND function in Excel)(Creswell & Creswell, 2017 ). To help ensure representativeness, proportional sampling was conducted across departments(Fink, 2024 ). The inclusion criteria were: (1) possession of a valid nurse license, (2) at least one year of independent clinical experience, and (3) current full-time employment in the selected hospital. Nurses on leave or assigned to satellite campuses were excluded(Polit & Beck, 2008 ). A total of 460 nurses completed the survey. All participants provided informed consent, and participation was voluntary and anonymous. 3.3 Data Collection Procedure Data were collected between September and November 2024 using a secure online survey platform commonly used in China. Prior to distribution, the nursing departments of the selected hospitals approved the research protocol and facilitated internal coordination. Nurses were invited to participate via hospital intranet announcements and departmental communication channels. The online questionnaire included a cover page outlining the study's objectives, ethical protections, and data use policy. Informed consent was obtained digitally before the participants could proceed. To maximize response accuracy and reduce social desirability bias, participants were assured of confidentiality and anonymity. This study received ethical approval from the institutional review board of Shanghai Tenth People’s Hospital, and it adhered to the ethical principles outlined in the Declaration of Helsinki. 3.4 Measurement Instruments All measures were self-reported and adapted from validated instruments with shown reliability in healthcare settings. 3.4.1 Transformational Leadership Transformational leadership was measured using the Multifactor Leadership Questionnaire (MLQ) developed by Bass and Avolio(1996). It includes five dimensions: inspirational motivation, idealized influence, intellectual stimulation, individualized consideration, and idealized behavior. Each item was rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Cronbach’s alpha for this scale was 0.87. 3.4.2 Nurse Self-Efficacy Nurse self-efficacy was measured using the Nursing Profession Self-Efficacy Scale – Version 2 (NPSES2) by Magon et al(2023). It covers two subscales: Care Delivery and Professionalism. Items were scored on a 5-point Likert scale (1 = completely disagree to 5 = completely agree). Cronbach’s alpha was 0.86 in this study. 3.4.3 Job Performance Nurse job performance was measured using the Nurse Job Performance Scale developed by Wang et al.(Wang et al., 2015 ), covering three domains: work coordination, work enthusiasm, and work involvement. Each item was rated on a 5-point Likert scale. Cronbach’s alpha was 0.86. Note All instruments were forward- and back-translated between English and Chinese following WHO translation guidelines(Organization, 2009 ). A pilot test with 30 nurses confirmed item clarity and response consistency(Creswell & Creswell, 2017 ). 3.5 Data Analysis Data were analyzed using SPSS 25.0 and AMOS 25.0. The following steps were undertaken: Preliminary Analysis: Descriptive statistics, skewness and kurtosis tests, and Pearson correlations were computed to assess normality and inter-variable associations(Tabachnick, 2007 ). Measurement Model Assessment: Confirmatory factor analysis (CFA) was conducted to assess the validity and reliability of latent constructs, using composite reliability (CR), average variance extracted (AVE), and discriminant validity criteria(Fornell & Larcker, 1981 ). Structural Model Assessment: Covariance-based SEM was used to test the hypothesized paths. Model fit was evaluated using χ²/df, RMSEA, CFI, TLI, and SRMR(Kline, 2023 ). Mediation Testing: Bootstrapping with 5,000 samples was used to assess indirect effects. A 95% confidence interval (CI) not including zero indicated significant mediation(Preacher & Hayes, 2008 ). Bias Control: Harman’s single-factor test was used to examine common method variance. The first factor accounted for less than 40% of the total variance, suggesting that common method bias was not a major concern(Podsakoff et al., 2003 ). A significance level of p < 0.05 was adopted for all analyses(Field, 2024 ). 4. Results 4.1 Participant Characteristics Table 1 summarizes the demographic characteristics of the 460 nurses who completed the survey. The sample was predominantly female (89.6%), with participants ranging in age from 20 to 55 years (M = 32.4, SD = 6.2). Most respondents held a bachelor’s degree (64.8%) and had more than five years of work experience (64.1%). Table 1 Participant Demographic Characteristics Variable​​ ​​Category​​ n %​ ​​Sex​​ Male 48 10.4 Female 412 89.6 Age < 25 62 13.5 25–34 238 51.7 35–44 128 27.8 ≥ 45 32 7.0 ​​Education Junior college or below 124 27.0 Bachelor’s 298 64.8 Master’s or above 38 8.2 ​​Work Experience 1–5 years 165 35.9 6–10 years 142 30.9 > 10 years 153 33.2 4.2 Descriptive Statistics and Correlations Table 2 displays the descriptive statistics and Pearson correlation coefficients among the three main variables. All variables exhibited approximately normal distributions (skewness < ± 1.0; kurtosis < ± 2.0). Job performance had the highest mean score (M = 4.21, SD = 0.43), followed by self-efficacy (M = 4.05, SD = 0.58), and transformational leadership (M = 3.82, SD = 0.62). All correlations were positive and statistically significant, with the strongest association observed between self-efficacy and job performance (r = 0.52, p < 0.01). Table 2 Descriptive Statistics and Correlation Matrix Variable​​ ​M ± SD​​ 1 2 3 1. Nurse Manager Leadership 3.82 ± 0.62 1 2. Nurse Self-efficacy 4.05 ± 0.58 0.41**​ 1 3. Nurse Job Performance 4.21 ± 0.43 0.38**​ 0.52**​ 1 Note: p < 0.01 (two-tailed). 4.3 Measurement Model Evaluation Confirmatory factor analysis (CFA) was conducted to evaluate the measurement model. All factor loadings were statistically significant (p < 0.001) and exceeded the 0.70 threshold, indicating strong item-level reliability. The model shown excellent fit: χ²/df = 2.14 CFI = 0.97 TLI = 0.96 RMSEA = 0.05 SRMR = 0.04 Construct reliability (CR) values were above 0.80, and average variance extracted (AVE) exceeded 0.50 for all constructs. Discriminant validity was supported, as the square roots of AVE exceeded inter-construct correlations. 4.4 Structural Model and Hypothesis Testing The structural model explained 34% of the variance in nurse job performance (R² = 0.34). All three hypothesized relationships were supported: H1: Transformational leadership was positively associated with nurse self-efficacy (β = 0.33, p < 0.001). H2: Nurse self-efficacy was positively associated with job performance (β = 0.47, p < 0.001). H3: Transformational leadership was positively associated with job performance (β = 0.18, p < 0.001). These results indicate that nurse self-efficacy is both a direct predictor of performance and a psychological pathway through which leadership exerts influence (see Table 3 ). Table 3 Standardized Path Coefficients Path​​ ​​β​​ ​​SE​​ t ​ ​​p​​ 95%CI​​ Nurse Manager Leadership → Self-efficacy 0.33 0.05 6.60 < 0.001 [0.24, 0.42] Nurse Self-efficacy → Job Performance 0.47 0.06 7.83 < 0.001 [0.35, 0.59] Nurse Manager Leadership → Job Performance 0.18 0.04 4.50 < 0.001 [0.10, 0.26] 4.5 Mediation Analysis Bootstrapping with 5,000 resamples confirmed that self-efficacy partially mediated the relationship between transformational leadership and job performance. Indirect effect: β = 0.15, SE = 0.03, 95% CI [0.09, 0.21] Proportion mediated: 46.3% of the total effect This supports H4 and underscores self-efficacy as a key psychological mechanism linking leadership behavior to improved performance (see Table 4 ). Table 4 Mediation Results Mediation Path​​ Indirect Effect​​ ​​SE​​ ​95% CI​​ % Mediated​ Leadership → Self-efficacy → Performance 0.15 0.03 [0.09, 0.21] 46.3% 4.6 Structural Model Visualization Figure 2 depicts the full structural model with standardized path coefficients and item loadings. All observed variables loaded strongly onto their respective latent constructs, and all structural paths were statistically significant (p < .001). Notably, self-efficacy showed the strongest direct association with job performance, emphasizing its central role in the model. All item loadings ≥ .78; all paths significant at p < .001. 5. Discussion 5.1 Summary of Main Findings This study investigated the relationships among transformational leadership, nurse self-efficacy, and job performance in tertiary hospital settings in China. The findings revealed that transformational leadership was positively associated with both nurse self-efficacy and job performance, and that nurse self-efficacy served as a partial mediator in this relationship. These results underscore self-efficacy as a key psychological mechanism through which leadership behaviors could affect nursing performance outcomes. Importantly, self-efficacy emerged as the strongest direct predictor of job performance in this model, underscoring the significance of nurses’ belief in their clinical competence and autonomy in achieving high levels of performance in high-stakes hospital environments. 5.2 Integration with Prior Literature The positive association between transformational leadership and nurse self-efficacy aligns with recent studies showing that transformational leadership positively affects nurses’ work engagement and extra-role performance by enhancing self‑efficacy through emotional support and mentorship(Ma & Ma, 2025 ). Our findings also support the JD-R model, which positions leadership as a key job resource that enhances psychological capital (e.g., self‑efficacy), particularly under high-stress work conditions like those in tertiary healthcare(Alsadaan et al., 2023 ). The strong link between self-efficacy and job performance corroborates previous research indicating that nurses with high self-confidence demonstrate greater task persistence, adaptability, and coordination—especially in demanding hospital settings. This finding extends the JD-R model by providing empirical evidence that psychological resources not only buffer against stress but actively contribute to measurable performance gains(Bakker & Demerouti, 2017 ). 5.3 Cultural and Organizational Context While the constructs of leadership, self-efficacy, and performance are globally relevant, their manifestations may differ across cultural and structural contexts. In China, healthcare institutions operate under rigid bureaucratic hierarchies, with centralized decision-making and clearly defined authority lines. These conditions may amplify the impact of transformational leadership, as staff members often rely on direct superiors for motivational cues and developmental feedback(Ystaas et al., 2023 ). Moreover, Confucian cultural values such as respect for hierarchy, collectivism, and emotional restraint may shape how nurses perceive and respond to leadership behaviors. For instance, leaders who demonstrate individualized consideration may be perceived not only as supportive but also as morally upright, thus reinforcing role modeling effects more strongly than in Western settings(Hu, 2024 ). Despite these insights, our model did not explicitly include structural or cultural moderators such as perceived organizational support or power distance. Future studies may incorporate these variables to capture the full complexity of leadership dynamics in Chinese healthcare systems. Notably, cross-cultural research shows that power distance orientation moderates follower responses to leadership behavior in high power-distance societies(Lin & Sun, 2018 ). 5.4 Theoretical Implications This study contributes to the literature in several ways. First, it integrates two major psychological frameworks—social cognitive theory and the JD-R model—to examine a mediation process in a high-demand clinical context. While previous studies have explored these frameworks separately, few have combined them in the context of nurse performance(Cabrera-Aguilar et al., 2023 ; Mi & Xi, 2025 ). Second, by identifying nurse self-efficacy as a partial mediator, the study advances theoretical understanding of how leadership exerts influence through both direct and psychological pathways. This dual-channel explanation enhances the explanatory power of leadership theories by linking macro-level behaviors with micro-level beliefs and outcomes(Kulo, 2024 ; Park & Kim, 2023 ). Finally, this study contextualizes its findings within a healthcare system characterized by structural hierarchy and cultural specificity. It responds to recent calls in organizational behavior research for theory development that reflects the sociocultural realities of non-Western institutions(Park & Kim, 2023 ; Zhang, Jin, et al., 2025). 5.5 Practical Implications The findings offer several practical recommendations for hospital leadership and workforce development: Leadership development programs ought to prioritize transformational skills such as vision articulation, individualized mentoring, and emotional support. These behaviors are not only well-received by nursing staff but also instrumental in boosting psychological confidence. Recent research in Chinese tertiary hospitals shows that transformational leadership is associated with enhanced professional identity, self-efficacy, and reduced burnout among nurses, especially in ICU settings(Guo et al., 2022 ). Self-efficacy training could be integrated into continuing education, simulation exercises, and performance feedback systems. Nurse educators and managers can design interventions aimed at reinforcing clinical confidence through mastery experiences, positive reinforcement, and peer modeling. A recent meta-analysis confirmed that simulation-based training significantly improves nurses’ self-efficacy and clinical decision-making in high-stakes environments(Lugo et al., 2021 ; Wei et al., 2024 ). Organizational support mechanisms such as feedback loops, participatory governance, and recognition systems ought to be improved to sustain both leadership impact and nurse motivation. Empirical studies suggest that perceived organizational support enhances nurses’ work engagement and buffers against emotional exhaustion, particularly when combined with transformational leadership(Tian et al., 2023 ). Contextual sensitivity is key. Leadership interventions ought to be tailored to the hierarchical and collectivist culture of Chinese hospitals, where respectful authority, emotional stability, and group cohesion are highly valued. Recent culturally contextualized leadership studies underscore that Confucian values (e.g., respect for authority, relational harmony) amplify the role-modeling impact of transformational leadership in Chinese clinical teams(Shi et al., 2023 ). 5.6 Limitations and Directions for Future Research Several limitations must be acknowledged. First, the study employed a cross-sectional design and self-report measures, limiting the ability to draw causal inferences. While SEM and bootstrapping enhance analytical rigor, future studies could use longitudinal or time-lagged designs to verify mediation pathways. Recent leadership studies in nursing contexts have begun to employ two-wave or panel designs to strengthen causal interpretation, particularly in mediation testing(Boamah, 2022 ). Second, although stratified random sampling was used within selected hospitals, the sample was drawn from a single metropolitan region. Generalizability to rural or private healthcare settings remains limited. Previous research has shown that leadership perceptions and outcomes can vary significantly across urban–rural healthcare institutions in China(Ma et al., 2021 ). Third, while the study focused on leadership and self-efficacy, it did not control for potentially influential contextual variables such as department type, shift arrangements, or organizational climate. Prior research has shown that organizational climate plays a mediating role in the relationship between transformational leadership and work engagement among ICU nurses, highlighting its importance in explaining how leadership impacts nurse outcomes(Hasan et al., 2023 ). Future studies should consider including such contextual and team-level factors to better capture the complexity of leadership effectiveness and refine model precision. Finally, cultural constructs such as power distance, trust in authority, and perceived fairness warrant further empirical testing as potential moderators in the relationship between leadership and staff outcomes. Zhang et al(2025). demonstrated that organizational climate, which reflects shared psychological perceptions shaped by cultural norms, mediates the impact of transformational leadership on nurses’ work engagement in intensive care settings. Building on this, future studies should examine how individual-level cultural values (e.g. power distance orientation) and organizational-level factors (e.g. climate, perceived fairness) interact to condition the effectiveness of leadership in hierarchical, collectivist healthcare environments. 6. Conclusion This study examined how transformational leadership influences nurse job performance through the mediating role of self-efficacy in Chinese tertiary hospitals. By integrating social cognitive theory and the JD-R model, the findings underscore self-efficacy as a key psychological mechanism linking leadership to performance in hierarchical healthcare settings. The study contributes to leadership theory by identifying dual pathways—direct and psychological—through which leadership may affect outcomes. It also provides contextual insights into how leadership is enacted and received in collectivist, authority-sensitive cultures. Future research ought to explore causal mechanisms using longitudinal designs and consider structural or cultural moderators to deepen understanding of leadership effectiveness in diverse healthcare environments. Declarations Ethics approval and consent to participate This study was approved by the Joint Ethics Committee of Shanghai Tenth People’s Hospital (approval number: 24KT115). Written informed consent was obtained from all participants prior to data collection. This study adhered to the Declaration of Helsinki. Consent for publication Not applicable. Funding No funding was obtained for this study. Author Contribution YJ conceptualized and designed the study, conducted data collection, analysis, and drafted the manuscript. MK contributed to study design, interpretation of data, and critical revision of the manuscript. TF assisted with data collection, analysis, and manuscript revision. All authors read and approved the final manuscript. Acknowledgement Not applicable. 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The relationship between transformational leadership and work engagement among intensive care unit nurses: the mediating function of organizational climate. BMC nursing , 24 (1), 398. Zhang, L., Jin, X., Cheng, N., Wang, R., Liang, X., Fan, H., & Jiang, X. (2025). Work-family balance mediates self-efficacy and subjective well-being among nurses in Chinese intensive care units: a cross-sectional study. Applied Nursing Research , 82 , 151932. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7007454","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":483450645,"identity":"8b675bc7-f1ee-4e8f-bf69-73d4ec279462","order_by":0,"name":"Yuan Jiang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuklEQVRIiWNgGAWjYHACZgYJBhsefv4G0rSkyUjOOECKFgaGwzYGDQlEqpefkXzYwLLtPI8BwwHGDx9ziNBicCMtOUGy7TaPOXMDs+TMbcRokcgxPgDSYtlwgI2Zlxgt8jPyPwO1nOMxOJBApBaGGznMQIcdIEGLwZlnxgYS55J5JGccbCbOL/LtyY+lJcrs7Pn5mw9++EiUwwQSGJgl2UAsxgZi1AMB/wEGxg9/iFQ8CkbBKBgFIxMAAMOENMIj4RYUAAAAAElFTkSuQmCC","orcid":"","institution":"Shanghai Tenth People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Jiang","suffix":""},{"id":483450647,"identity":"b315712a-1e79-4cf3-8d6b-d0537bc08fe4","order_by":1,"name":"Minghao Kong Degree","email":"","orcid":"","institution":"Shanghai Tenth People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Minghao","middleName":"Kong","lastName":"Degree","suffix":""}],"badges":[],"createdAt":"2025-06-30 07:23:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7007454/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7007454/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86661703,"identity":"363257fd-6f64-4ff2-88e6-df9e673f6eab","added_by":"auto","created_at":"2025-07-14 10:39:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64768,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual Model of Hypothesized Relationships\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7007454/v1/c59fe7a9ab41bcb5e260e967.png"},{"id":86661705,"identity":"6cef59e7-d231-4709-bfe0-32f4e4d996c5","added_by":"auto","created_at":"2025-07-14 10:39:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":84937,"visible":true,"origin":"","legend":"\u003cp\u003eStructural equation model with standardized path coefficients.\u003c/p\u003e\n\u003cp\u003eAll item loadings ≥ .78; all paths significant at p \u0026lt; .001.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7007454/v1/aa91ac3fb89fcf0e9569e4be.png"},{"id":91063894,"identity":"1950c92f-e25b-47ea-8179-52d7fa8accc3","added_by":"auto","created_at":"2025-09-11 09:32:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1208157,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7007454/v1/fcfcc0b1-efc8-43e3-bf94-cc24510dedc4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Transformational Leadership, Self-Efficacy, and Job Performance in Chinese Tertiary Hospital Nurses: A Cross-Sectional Structural Equation Model Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eIn an era of increasingly complex patient needs, workforce shortages, and rising healthcare demands, the performance of nurses has emerged as a critical determinant of care quality and system efficiency(Aung Po et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Nurses represent the largest group of frontline healthcare professionals and are responsible not only for clinical procedures but also for coordination, advocacy, and patient-centered decision-making(Nguyen et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). As health systems continue to evolve under pressure, ensuring high levels of nurse performance has become a central concern for healthcare institutions worldwide(Al-Ajarmeh et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Krijgsheld et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite its recognized importance, nurse job performance is subject to a range of organizational and psychological influences(Simanjuntak et al., \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), particularly in tertiary hospitals where clinical workloads are heavy and administrative structures are rigid(Hao et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kumar \u0026amp; Bardhan, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In China, tertiary Grade-A hospitals serve as the backbone of urban healthcare delivery(Li \u0026amp; Zhao, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Y. Li et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). These institutions are characterized by hierarchical structures, resource concentration, and growing expectations for quality assurance, making them ideal but challenging environments in which to examine factors that influence nurse performance(Chen et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Fu et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). A key concern in such contexts is how leadership and psychological resources interact to shape performance outcomes(Alsadaan et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTransformational leadership has garnered growing attention in healthcare literature as a leadership style capable of motivating, empowering, and psychologically supporting staff(Niinihuhta et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ystaas et al., \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Defined by qualities such as inspirational motivation, individualized consideration, and intellectual stimulation, transformational leadership is associated with improved staff engagement, innovation, and resilience(Khan et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, the mechanisms through which transformational leadership affects nurse performance remain underexplored, especially in cultural contexts where deference to authority, formal hierarchy, and limited autonomy may constrain leadership impact(Hsiu-Ying et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Understanding how transformational leadership operates within such constraints is vital for theory development and practical implementation(Broome, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOne potential pathway linking leadership to performance lies in self-efficacy\u0026mdash;nurses\u0026rsquo; belief in their ability to handle job-specific tasks effectively(Kim et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). According to Bandura\u0026rsquo;s social cognitive theory, self-efficacy serves as a core determinant of behavioral motivation, decision-making, and persistence under pressure(Bandura, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e1991\u003c/span\u003e). In parallel, the Job Demands\u0026ndash;Resources (JD-R) model identifies self-efficacy as a psychological resource that buffers job stressors and facilitates performance(Rhee et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). These two frameworks, when integrated, provide a robust basis for exploring how transformational leadership could affect performance through psychological empowerment mechanisms(Katou et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Yet few studies have combined these theories to empirically test their synergy, particularly in high-demand and high-structure healthcare environments(Kaiser et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Romero-Carazas et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition, research on these constructs has largely focused on Western settings(Broome, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Lin et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). While some studies have examined transformational leadership in Chinese nursing contexts, few have empirically explored how leadership behaviors translate into perceived self-efficacy and subsequent performance within the unique cultural and institutional constraints of Chinese tertiary hospitals(Sun et al., \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Xie et al., \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Elements such as power distance, collectivist norms, and bureaucratic coordination may not only shape how leadership is enacted but also influence how it is interpreted and internalized by staff(Li et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). These contextual dynamics are frequently overlooked in models derived from Western organizational psychology(Bui et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Erez, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTherefore, this study aims to examine the interrelationships between transformational leadership, nurse self-efficacy, and job performance among nurses working in tertiary hospitals in China. Drawing from Bandura\u0026rsquo;s social cognitive theory and the JD-R model, we test a mediation model in which nurse self-efficacy partially mediates the relationship between transformational leadership and nurse job performance(Cabrera-Aguilar et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). By integrating two theoretical perspectives and situating the study in a culturally specific healthcare context, this research contributes to the understanding of psychological mechanisms through which leadership could affect performance, and offers practical insights for nursing leadership development in high-intensity, hierarchical environments(Ying et al., \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e"},{"header":"2. Literature Review and Theoretical Framework","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Theoretical Foundations\u003c/h2\u003e\u003cp\u003eThis study is grounded in two complementary theoretical frameworks: Bandura\u0026rsquo;s social cognitive theory and the Job Demands\u0026ndash;Resources (JD-R) model. Bandura (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e1991\u003c/span\u003e)emphasizes the role of self-efficacy\u0026mdash;individuals\u0026rsquo; beliefs in their capabilities to perform specific tasks\u0026mdash;as a critical determinant of motivation, resilience, and performance. In nursing contexts, self-efficacy is associated with improved decision-making, persistence under stress, and confidence in clinical execution(AL Btoush et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Lee \u0026amp; Ko, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe JD-R model(Demerouti et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2001\u003c/span\u003e), on the other hand, conceptualizes employee well-being and performance as functions of the balance between job demands and job resources. Among the most powerful job resources are supportive leadership behaviors, which can reduce strain and bolster psychological resources such as self-efficacy(Tummers \u0026amp; Bakker, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The model also accommodates structural and organizational influences, making it particularly suitable for analyzing high-stress, high-intensity workplaces such as tertiary hospitals(Mazzetti et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBy integrating these two frameworks, we propose that transformational leadership\u0026mdash;a form of leadership rich in vision, mentorship, and psychological support\u0026mdash;serves as a contextual job resource that enhances nurses\u0026rsquo; self-efficacy, which in turn promotes job performance(Lai et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Wu et al., \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). This integration enables a multilevel understanding of both psychological (self-belief) and structural (leadership) factors shaping performance(Orlowska \u0026amp; Laguna, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Transformational Leadership in Nursing Contexts\u003c/h2\u003e\u003cp\u003eTransformational leadership is defined by four core dimensions: idealized influence, inspirational motivation, intellectual stimulation, and individualized consideration(Bass \u0026amp; Riggio, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). These qualities allow leaders to inspire shared goals, encourage staff innovation, and provide personalized support, which are especially relevant in complex healthcare environments(Brewer et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Moon et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePrior studies have shown that transformational leadership enhances nurse performance through multiple pathways\u0026mdash;including empowerment, emotional support, and communication(Alwali \u0026amp; Alwali, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, the effects may vary depending on contextual features such as hierarchical structure and cultural norms(Hasan et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In Chinese tertiary hospitals, where vertical authority structures prevail and autonomy may be constrained, transformational leadership may play an even more pivotal role in enhancing staff psychological readiness and motivation(Chu et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Nurse Self-Efficacy\u003c/h2\u003e\u003cp\u003eSelf-efficacy refers to a nurse\u0026rsquo;s confidence in handling job-specific demands, including patient care, interprofessional communication, and clinical judgment(Mehralian et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Bandura\u0026rsquo;s theory posits that individuals with high self-efficacy are more likely to approach difficult tasks as challenges to be mastered rather than threats to be avoided(Bandura, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e1991\u003c/span\u003e). The JD-R model similarly identifies self-efficacy as a core psychological resource that buffers stress and facilitates job effectiveness(Demerouti et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRecent studies suggest that nurse self-efficacy correlates positively with job satisfaction, teamwork, and adaptive coping(Kallerhult Hermansson et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Despite its central role, few studies have examined how organizational factors\u0026mdash;particularly leadership\u0026mdash;can cultivate self-efficacy within culturally structured systems such as Chinese hospitals(J. Li et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Nurse Job Performance\u003c/h2\u003e\u003cp\u003eNurse job performance encompasses technical skills, interpersonal coordination, work engagement, and the quality of patient care delivered(Sarık\u0026ouml;se \u0026amp; G\u0026ouml;ktepe, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). It reflects not only clinical competence but also the ability to manage complex workloads, adhere to safety standards, and collaborate across units(Al-Ajarmeh et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Given China\u0026rsquo;s increasing healthcare demands and workforce pressure, understanding predictors of nurse performance has become a strategic imperative(Zhang et al., \u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEmpirical evidence shows that job performance is positively influenced by psychological empowerment, professional identity, and leadership quality(Al Otaibi et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, most studies focus on direct effects, and few have explored psychological mediation mechanisms such as self-efficacy within hierarchical systems(Wang et al., \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The present study addresses this gap.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Hypothesis Development\u003c/h2\u003e\u003cp\u003eBased on the above theoretical foundation and empirical insights, we propose the following hypotheses:\u003c/p\u003e\u003cp\u003eH1: Transformational leadership is positively associated with nurse self-efficacy.\u003c/p\u003e\u003cp\u003eRationale: Transformational leaders provide emotional support, mentoring, and clear expectations, which facilitate psychological confidence(Wu et al., \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eH2: Nurse self-efficacy is positively associated with job performance.\u003c/p\u003e\u003cp\u003eRationale: High self-efficacy promotes persistence, proactive behavior, and confidence in decision-making, which contribute to higher performance(Kurniawan et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eH3: Transformational leadership is positively associated with job performance.\u003c/p\u003e\u003cp\u003eRationale: Leaders who clarify goals, provide feedback, and encourage innovation can improve nurse effectiveness through both motivational and procedural pathways(Boamah et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Gebreheat et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eH4: Nurse self-efficacy partially mediates the relationship between transformational leadership and job performance.\u003c/p\u003e\u003cp\u003eRationale: Leadership influences job performance both directly and indirectly by enhancing nurses\u0026rsquo; belief in their professional capability(Djourova et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Conceptual Model\u003c/h2\u003e\u003cp\u003eThe conceptual model guiding this study is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. It reflects the hypothesized pathways between transformational leadership, nurse self-efficacy, and job performance, integrating cognitive and organizational dimensions.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Methods","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Research Design\u003c/h2\u003e\u003cp\u003eThis study employed a quantitative, cross-sectional research design to examine the relationships between transformational leadership, nurse self-efficacy, and job performance. A structured online questionnaire was used to collect self-reported data from a sample of registered nurses. The design was guided by theoretical assumptions derived from social cognitive theory and the Job Demands\u0026ndash;Resources (JD-R) model, and was appropriate for testing the hypothesized mediation model using structural equation modeling (SEM)(Bandura, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Demerouti et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Kline, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Participants and Sampling\u003c/h2\u003e\u003cp\u003eA stratified random sampling method was used to recruit participants from three tertiary Grade-A general hospitals located in different districts of Shanghai, China(Creswell \u0026amp; Creswell, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). These hospitals were selected to represent a range of institutional contexts, including a central urban district, a mixed-use industrial-residential zone, and an emerging economic development area(You et al., \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWithin each hospital, lists of eligible clinical nurses were obtained from the nursing administration. Registered nurses were randomly selected using computer-generated random numbers (e.g., the RAND function in Excel)(Creswell \u0026amp; Creswell, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). To help ensure representativeness, proportional sampling was conducted across departments(Fink, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The inclusion criteria were: (1) possession of a valid nurse license, (2) at least one year of independent clinical experience, and (3) current full-time employment in the selected hospital. Nurses on leave or assigned to satellite campuses were excluded(Polit \u0026amp; Beck, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA total of 460 nurses completed the survey. All participants provided informed consent, and participation was voluntary and anonymous.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Data Collection Procedure\u003c/h2\u003e\u003cp\u003eData were collected between September and November 2024 using a secure online survey platform commonly used in China. Prior to distribution, the nursing departments of the selected hospitals approved the research protocol and facilitated internal coordination. Nurses were invited to participate via hospital intranet announcements and departmental communication channels.\u003c/p\u003e\u003cp\u003eThe online questionnaire included a cover page outlining the study's objectives, ethical protections, and data use policy. Informed consent was obtained digitally before the participants could proceed. To maximize response accuracy and reduce social desirability bias, participants were assured of confidentiality and anonymity.\u003c/p\u003e\u003cp\u003e This study received ethical approval from the institutional review board of Shanghai Tenth People\u0026rsquo;s Hospital, and it adhered to the ethical principles outlined in the Declaration of Helsinki.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Measurement Instruments\u003c/h2\u003e\u003cp\u003eAll measures were self-reported and adapted from validated instruments with shown reliability in healthcare settings.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003e3.4.1 Transformational Leadership\u003c/h2\u003e\u003cp\u003eTransformational leadership was measured using the Multifactor Leadership Questionnaire (MLQ) developed by Bass and Avolio(1996). It includes five dimensions: inspirational motivation, idealized influence, intellectual stimulation, individualized consideration, and idealized behavior. Each item was rated on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly disagree to 5\u0026thinsp;=\u0026thinsp;strongly agree). Cronbach\u0026rsquo;s alpha for this scale was 0.87.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e3.4.2 Nurse Self-Efficacy\u003c/h2\u003e\u003cp\u003eNurse self-efficacy was measured using the Nursing Profession Self-Efficacy Scale \u0026ndash; Version 2 (NPSES2) by Magon et al(2023). It covers two subscales: Care Delivery and Professionalism. Items were scored on a 5-point Likert scale (1\u0026thinsp;=\u0026thinsp;completely disagree to 5\u0026thinsp;=\u0026thinsp;completely agree). Cronbach\u0026rsquo;s alpha was 0.86 in this study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e3.4.3 Job Performance\u003c/h2\u003e\u003cp\u003eNurse job performance was measured using the Nurse Job Performance Scale developed by Wang et al.(Wang et al., \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), covering three domains: work coordination, work enthusiasm, and work involvement. Each item was rated on a 5-point Likert scale. Cronbach\u0026rsquo;s alpha was 0.86.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eNote\u003c/strong\u003e\u003cp\u003eAll instruments were forward- and back-translated between English and Chinese following WHO translation guidelines(Organization, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). A pilot test with 30 nurses confirmed item clarity and response consistency(Creswell \u0026amp; Creswell, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Data Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS 25.0 and AMOS 25.0. The following steps were undertaken:\u003c/p\u003e\u003cp\u003ePreliminary Analysis: Descriptive statistics, skewness and kurtosis tests, and Pearson correlations were computed to assess normality and inter-variable associations(Tabachnick, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMeasurement Model Assessment: Confirmatory factor analysis (CFA) was conducted to assess the validity and reliability of latent constructs, using composite reliability (CR), average variance extracted (AVE), and discriminant validity criteria(Fornell \u0026amp; Larcker, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1981\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eStructural Model Assessment: Covariance-based SEM was used to test the hypothesized paths. Model fit was evaluated using χ\u0026sup2;/df, RMSEA, CFI, TLI, and SRMR(Kline, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMediation Testing: Bootstrapping with 5,000 samples was used to assess indirect effects. A 95% confidence interval (CI) not including zero indicated significant mediation(Preacher \u0026amp; Hayes, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBias Control: Harman\u0026rsquo;s single-factor test was used to examine common method variance. The first factor accounted for less than 40% of the total variance, suggesting that common method bias was not a major concern(Podsakoff et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2003\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was adopted for all analyses(Field, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Results","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Participant Characteristics\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the demographic characteristics of the 460 nurses who completed the survey. The sample was predominantly female (89.6%), with participants ranging in age from 20 to 55 years (M\u0026thinsp;=\u0026thinsp;32.4, SD\u0026thinsp;=\u0026thinsp;6.2). Most respondents held a bachelor\u0026rsquo;s degree (64.8%) and had more than five years of work experience (64.1%).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Demographic Characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable​​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e​​Category​​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%​\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e​​Sex​​\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e412\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e89.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u0026ndash;34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e238\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35\u0026ndash;44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e128\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e27.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e​​Education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJunior college or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e27.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor\u0026rsquo;s\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e298\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e64.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster\u0026rsquo;s or above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e​​Work Experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e165\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e35.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e153\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Descriptive Statistics and Correlations\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e displays the descriptive statistics and Pearson correlation coefficients among the three main variables. All variables exhibited approximately normal distributions (skewness\u0026thinsp;\u0026lt;\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0; kurtosis\u0026thinsp;\u0026lt;\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0).\u003c/p\u003e\u003cp\u003eJob performance had the highest mean score (M\u0026thinsp;=\u0026thinsp;4.21, SD\u0026thinsp;=\u0026thinsp;0.43), followed by self-efficacy (M\u0026thinsp;=\u0026thinsp;4.05, SD\u0026thinsp;=\u0026thinsp;0.58), and transformational leadership (M\u0026thinsp;=\u0026thinsp;3.82, SD\u0026thinsp;=\u0026thinsp;0.62). All correlations were positive and statistically significant, with the strongest association observed between self-efficacy and job performance (r\u0026thinsp;=\u0026thinsp;0.52, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive Statistics and Correlation Matrix\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable​​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e​M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD​​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Nurse Manager Leadership\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Nurse Self-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e4.05\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.41**​\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Nurse Job Performance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e4.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.38**​\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.52**​\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 (two-tailed).\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Measurement Model Evaluation\u003c/h2\u003e\u003cp\u003eConfirmatory factor analysis (CFA) was conducted to evaluate the measurement model. All factor loadings were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and exceeded the 0.70 threshold, indicating strong item-level reliability. The model shown excellent fit:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eχ\u0026sup2;/df\u0026thinsp;=\u0026thinsp;2.14\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCFI\u0026thinsp;=\u0026thinsp;0.97\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTLI\u0026thinsp;=\u0026thinsp;0.96\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eRMSEA\u0026thinsp;=\u0026thinsp;0.05\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSRMR\u0026thinsp;=\u0026thinsp;0.04\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eConstruct reliability (CR) values were above 0.80, and average variance extracted (AVE) exceeded 0.50 for all constructs. Discriminant validity was supported, as the square roots of AVE exceeded inter-construct correlations.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Structural Model and Hypothesis Testing\u003c/h2\u003e\u003cp\u003eThe structural model explained 34% of the variance in nurse job performance (R\u0026sup2; = 0.34). All three hypothesized relationships were supported:\u003c/p\u003e\u003cp\u003eH1: Transformational leadership was positively associated with nurse self-efficacy (β\u0026thinsp;=\u0026thinsp;0.33, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eH2: Nurse self-efficacy was positively associated with job performance (β\u0026thinsp;=\u0026thinsp;0.47, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eH3: Transformational leadership was positively associated with job performance (β\u0026thinsp;=\u0026thinsp;0.18, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eThese results indicate that nurse self-efficacy is both a direct predictor of performance and a psychological pathway through which leadership exerts influence (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStandardized Path Coefficients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePath​​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e​​β​​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e​​SE​​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003et ​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e​​p​​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e95%CI​​\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse Manager Leadership \u0026rarr; Self-efficacy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e[0.24, 0.42]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse Self-efficacy \u0026rarr; Job Performance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e[0.35, 0.59]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse Manager Leadership \u0026rarr; Job Performance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e[0.10, 0.26]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Mediation Analysis\u003c/h2\u003e\u003cp\u003eBootstrapping with 5,000 resamples confirmed that self-efficacy partially mediated the relationship between transformational leadership and job performance.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eIndirect effect: β\u0026thinsp;=\u0026thinsp;0.15, SE\u0026thinsp;=\u0026thinsp;0.03, 95% CI [0.09, 0.21]\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eProportion mediated: 46.3% of the total effect\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThis supports H4 and underscores self-efficacy as a key psychological mechanism linking leadership behavior to improved performance (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMediation Results\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMediation Path​​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndirect Effect​​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e​​SE​​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e​95% CI​​\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e% Mediated​\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeadership \u0026rarr; Self-efficacy \u0026rarr; Performance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.09, 0.21]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e46.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003e4.6 Structural Model Visualization\u003c/h2\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e depicts the full structural model with standardized path coefficients and item loadings. All observed variables loaded strongly onto their respective latent constructs, and all structural paths were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Notably, self-efficacy showed the strongest direct association with job performance, emphasizing its central role in the model.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAll item loadings\u0026thinsp;\u0026ge;\u0026thinsp;.78; all paths significant at p\u0026thinsp;\u0026lt;\u0026thinsp;.001.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Discussion","content":"\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\u003ch2\u003e5.1 Summary of Main Findings\u003c/h2\u003e\u003cp\u003eThis study investigated the relationships among transformational leadership, nurse self-efficacy, and job performance in tertiary hospital settings in China. The findings revealed that transformational leadership was positively associated with both nurse self-efficacy and job performance, and that nurse self-efficacy served as a partial mediator in this relationship. These results underscore self-efficacy as a key psychological mechanism through which leadership behaviors could affect nursing performance outcomes.\u003c/p\u003e\u003cp\u003eImportantly, self-efficacy emerged as the strongest direct predictor of job performance in this model, underscoring the significance of nurses\u0026rsquo; belief in their clinical competence and autonomy in achieving high levels of performance in high-stakes hospital environments.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e\u003ch2\u003e5.2 Integration with Prior Literature\u003c/h2\u003e\u003cp\u003eThe positive association between transformational leadership and nurse self-efficacy aligns with recent studies showing that transformational leadership positively affects nurses\u0026rsquo; work engagement and extra-role performance by enhancing self‑efficacy through emotional support and mentorship(Ma \u0026amp; Ma, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur findings also support the JD-R model, which positions leadership as a key job resource that enhances psychological capital (e.g., self‑efficacy), particularly under high-stress work conditions like those in tertiary healthcare(Alsadaan et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe strong link between self-efficacy and job performance corroborates previous research indicating that nurses with high self-confidence demonstrate greater task persistence, adaptability, and coordination\u0026mdash;especially in demanding hospital settings. This finding extends the JD-R model by providing empirical evidence that psychological resources not only buffer against stress but actively contribute to measurable performance gains(Bakker \u0026amp; Demerouti, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003e5.3 Cultural and Organizational Context\u003c/h2\u003e\u003cp\u003eWhile the constructs of leadership, self-efficacy, and performance are globally relevant, their manifestations may differ across cultural and structural contexts. In China, healthcare institutions operate under rigid bureaucratic hierarchies, with centralized decision-making and clearly defined authority lines. These conditions may amplify the impact of transformational leadership, as staff members often rely on direct superiors for motivational cues and developmental feedback(Ystaas et al., \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMoreover, Confucian cultural values such as respect for hierarchy, collectivism, and emotional restraint may shape how nurses perceive and respond to leadership behaviors. For instance, leaders who demonstrate individualized consideration may be perceived not only as supportive but also as morally upright, thus reinforcing role modeling effects more strongly than in Western settings(Hu, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite these insights, our model did not explicitly include structural or cultural moderators such as perceived organizational support or power distance. Future studies may incorporate these variables to capture the full complexity of leadership dynamics in Chinese healthcare systems. Notably, cross-cultural research shows that power distance orientation moderates follower responses to leadership behavior in high power-distance societies(Lin \u0026amp; Sun, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003e5.4 Theoretical Implications\u003c/h2\u003e\u003cp\u003eThis study contributes to the literature in several ways. First, it integrates two major psychological frameworks\u0026mdash;social cognitive theory and the JD-R model\u0026mdash;to examine a mediation process in a high-demand clinical context. While previous studies have explored these frameworks separately, few have combined them in the context of nurse performance(Cabrera-Aguilar et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Mi \u0026amp; Xi, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSecond, by identifying nurse self-efficacy as a partial mediator, the study advances theoretical understanding of how leadership exerts influence through both direct and psychological pathways. This dual-channel explanation enhances the explanatory power of leadership theories by linking macro-level behaviors with micro-level beliefs and outcomes(Kulo, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Park \u0026amp; Kim, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFinally, this study contextualizes its findings within a healthcare system characterized by structural hierarchy and cultural specificity. It responds to recent calls in organizational behavior research for theory development that reflects the sociocultural realities of non-Western institutions(Park \u0026amp; Kim, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Zhang, Jin, et al., 2025).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec30\" class=\"Section2\"\u003e\u003ch2\u003e5.5 Practical Implications\u003c/h2\u003e\u003cp\u003eThe findings offer several practical recommendations for hospital leadership and workforce development:\u003c/p\u003e\u003cp\u003eLeadership development programs ought to prioritize transformational skills such as vision articulation, individualized mentoring, and emotional support. These behaviors are not only well-received by nursing staff but also instrumental in boosting psychological confidence. Recent research in Chinese tertiary hospitals shows that transformational leadership is associated with enhanced professional identity, self-efficacy, and reduced burnout among nurses, especially in ICU settings(Guo et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSelf-efficacy training could be integrated into continuing education, simulation exercises, and performance feedback systems. Nurse educators and managers can design interventions aimed at reinforcing clinical confidence through mastery experiences, positive reinforcement, and peer modeling. A recent meta-analysis confirmed that simulation-based training significantly improves nurses\u0026rsquo; self-efficacy and clinical decision-making in high-stakes environments(Lugo et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Wei et al., \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOrganizational support mechanisms such as feedback loops, participatory governance, and recognition systems ought to be improved to sustain both leadership impact and nurse motivation. Empirical studies suggest that perceived organizational support enhances nurses\u0026rsquo; work engagement and buffers against emotional exhaustion, particularly when combined with transformational leadership(Tian et al., \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eContextual sensitivity is key. Leadership interventions ought to be tailored to the hierarchical and collectivist culture of Chinese hospitals, where respectful authority, emotional stability, and group cohesion are highly valued. Recent culturally contextualized leadership studies underscore that Confucian values (e.g., respect for authority, relational harmony) amplify the role-modeling impact of transformational leadership in Chinese clinical teams(Shi et al., \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003e5.6 Limitations and Directions for Future Research\u003c/h2\u003e\u003cp\u003eSeveral limitations must be acknowledged. First, the study employed a cross-sectional design and self-report measures, limiting the ability to draw causal inferences. While SEM and bootstrapping enhance analytical rigor, future studies could use longitudinal or time-lagged designs to verify mediation pathways. Recent leadership studies in nursing contexts have begun to employ two-wave or panel designs to strengthen causal interpretation, particularly in mediation testing(Boamah, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSecond, although stratified random sampling was used within selected hospitals, the sample was drawn from a single metropolitan region. Generalizability to rural or private healthcare settings remains limited. Previous research has shown that leadership perceptions and outcomes can vary significantly across urban\u0026ndash;rural healthcare institutions in China(Ma et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThird, while the study focused on leadership and self-efficacy, it did not control for potentially influential contextual variables such as department type, shift arrangements, or organizational climate. Prior research has shown that organizational climate plays a mediating role in the relationship between transformational leadership and work engagement among ICU nurses, highlighting its importance in explaining how leadership impacts nurse outcomes(Hasan et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Future studies should consider including such contextual and team-level factors to better capture the complexity of leadership effectiveness and refine model precision.\u003c/p\u003e\u003cp\u003eFinally, cultural constructs such as power distance, trust in authority, and perceived fairness warrant further empirical testing as potential moderators in the relationship between leadership and staff outcomes. Zhang et al(2025). demonstrated that organizational climate, which reflects shared psychological perceptions shaped by cultural norms, mediates the impact of transformational leadership on nurses\u0026rsquo; work engagement in intensive care settings. Building on this, future studies should examine how individual-level cultural values (e.g. power distance orientation) and organizational-level factors (e.g. climate, perceived fairness) interact to condition the effectiveness of leadership in hierarchical, collectivist healthcare environments.\u003c/p\u003e\u003c/div\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThis study examined how transformational leadership influences nurse job performance through the mediating role of self-efficacy in Chinese tertiary hospitals. By integrating social cognitive theory and the JD-R model, the findings underscore self-efficacy as a key psychological mechanism linking leadership to performance in hierarchical healthcare settings. The study contributes to leadership theory by identifying dual pathways\u0026mdash;direct and psychological\u0026mdash;through which leadership may affect outcomes. It also provides contextual insights into how leadership is enacted and received in collectivist, authority-sensitive cultures. Future research ought to explore causal mechanisms using longitudinal designs and consider structural or cultural moderators to deepen understanding of leadership effectiveness in diverse healthcare environments.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e This study was approved by the Joint Ethics Committee of Shanghai Tenth People\u0026rsquo;s Hospital (approval number: 24KT115). Written informed consent was obtained from all participants prior to data collection. This study adhered to the Declaration of Helsinki.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNo funding was obtained for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYJ conceptualized and designed the study, conducted data collection, analysis, and drafted the manuscript. MK contributed to study design, interpretation of data, and critical revision of the manuscript. TF assisted with data collection, analysis, and manuscript revision. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAl‐Ajarmeh, D. O., Rayan, A. H., Eshah, N. F., \u0026amp; Al‐Hamdan, Z. M. (2022). Nurse\u0026ndash;nurse collaboration and performance among nurses in intensive care units. \u003cem\u003eNursing in Critical Care\u003c/em\u003e,\u003cem\u003e 27\u003c/em\u003e(6), 747-755. \u003c/li\u003e\n\u003cli\u003eAL Btoush, M. R., Malak, M. Z., Hamaideh, S. H., \u0026amp; Shuhaiber, A. H. (2025). 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Work-family balance mediates self-efficacy and subjective well-being among nurses in Chinese intensive care units: a cross-sectional study. \u003cem\u003eApplied Nursing Research\u003c/em\u003e,\u003cem\u003e 82\u003c/em\u003e, 151932. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Transformational leadership, Nurse self-efficacy, Job performance, Structural equation modeling, JD-R model, China, Healthcare leadership","lastPublishedDoi":"10.21203/rs.3.rs-7007454/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7007454/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eNurse job performance is critical to healthcare quality, particularly in high-demand, hierarchical systems such as tertiary hospitals in China. While transformational leadership and self-efficacy are known to influence performance, their interaction remains underexplored in culturally structured healthcare contexts.\u003c/p\u003e\u003ch2\u003ePurpose:\u003c/h2\u003e\u003cp\u003eThis study investigates how transformational leadership relates to nurse job performance, with self-efficacy examined as a mediating mechanism. The model is grounded in Bandura\u0026rsquo;s social cognitive theory and the Job Demands\u0026ndash;Resources (JD-R) model.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA cross-sectional survey was conducted with 460 registered nurses from three tertiary Grade-A hospitals in Shanghai, selected via stratified random sampling. Self-reported data were collected using validated instruments: the Multifactor Leadership Questionnaire (MLQ), the Nursing Profession Self-Efficacy Scale (NPSES2), and the Nurse Job Performance Scale. Structural equation modeling (SEM) and bootstrapping were used to test direct and indirect effects.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eTransformational leadership was positively associated with both nurse self-efficacy (β\u0026thinsp;=\u0026thinsp;0.33, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and job performance (β\u0026thinsp;=\u0026thinsp;0.18, p\u0026thinsp;\u0026lt;\u0026thinsp;.001). Self-efficacy was the primary predictor of job performance (β\u0026thinsp;=\u0026thinsp;0.47, p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and partially mediated the leadership\u0026ndash;performance relationship, accounting for 46.3% of the total effect.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eThese findings support a dual-pathway model in which transformational leadership enhances performance both directly and through psychological empowerment. The results offer practical insights for leadership development and underscore the importance of fostering self-efficacy in demanding, hierarchical healthcare systems. Future research ought to explore longitudinal designs and cultural moderators to extend generalizability.\u003c/p\u003e","manuscriptTitle":"Transformational Leadership, Self-Efficacy, and Job Performance in Chinese Tertiary Hospital Nurses: A Cross-Sectional Structural Equation Model Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 10:38:55","doi":"10.21203/rs.3.rs-7007454/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8b2b92e6-6ce6-442c-8add-2f1d352b9127","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":51334123,"name":"Health sciences/Health care"},{"id":51334124,"name":"Health sciences/Health occupations"},{"id":51334125,"name":"Biological sciences/Psychology"},{"id":51334126,"name":"Social science/Psychology"}],"tags":[],"updatedAt":"2025-09-11T09:24:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-14 10:38:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7007454","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7007454","identity":"rs-7007454","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}