This article examines how transformational leadership shapes employees’ perceptions of organizational change in a hospital context, and it tests whether organizational culture operates as the mechanism through which leadership translates into change-related perceptions. The study is positioned within a contemporary hospital reality where change is not occasional but continuous, particularly in institutions simultaneously pursuing accreditation and digital transformation. By focusing on accredited and digitally certified public hospitals, the authors treat “change” as a complex, multi-layered organizational condition rather than a single project, and they frame leadership and culture as the two most actionable managerial levers for sustaining readiness and engagement during such transformations.
The paper’s core rationale is straightforward and strategically important: accreditation and digitalization are not merely technical upgrades or compliance exercises; they demand deep alterations in workflows, routines, decision rights, and the shared assumptions that guide daily work. These alterations are experienced at the employee level as uncertainty, increased cognitive load, and potential loss of control, which means that the success of change depends on how staff interpret the change process rather than only on formal implementation plans. The authors argue that hospitals can meet formal standards and still fail in practice if employees perceive change as illegitimate, poorly led, or culturally misaligned. In Türkiye, the subset of hospitals that have achieved both accreditation and digital hospital certification is limited, and the literature has not sufficiently tested how leadership, culture, and change perception interact specifically within this dual-transformation setting. This gap matters because the joint pressure of accreditation and digitalization creates a “high-change density” environment where leadership and culture may not behave as they do in more stable settings, making an empirical test in this context necessary rather than optional.
Conceptually, the study integrates three constructs: transformational leadership, organizational culture, and organizational change perception. Transformational leadership is treated as a behavioral pattern through which managers inspire, empower, and shape meaning, while organizational culture is operationalized through the competing values framework’s four culture types: adhocracy, clan, hierarchy, and market culture. Organizational change perception is conceptualized as a multi-dimensional employee response that includes cognitive, emotional, and behavioral components. The theoretical proposition is that leadership does not influence change perception in a vacuum; it influences the cultural environment, and that cultural environment then conditions how change is interpreted and enacted by staff. This results in a mediation logic where culture is not a background variable but an active channel through which leadership “reaches” employee perceptions.
Methodologically, the study employs a cross-sectional, explanatory design in two public hospitals in İzmir, Türkiye, both accredited and holding digital hospital certificates. Data were collected via face-to-face administration from a stratified sample to ensure professional representation, producing 527 valid responses after excluding incomplete forms. The authors used exploratory and confirmatory factor analyses to ensure measurement adequacy and then estimated a structural equation model. For mediation, they applied a parallel mediation approach and used bootstrap resampling (5,000 samples) to test indirect effects, aligning the inference strategy with contemporary mediation standards that emphasize confidence intervals rather than relying on single-step significance testing.
The measurement strategy is notable because it deliberately balances global comparability with local cultural fit. Transformational leadership is measured using a Turkish-context-adapted scale derived from prior work that emphasizes culturally salient relational leadership behaviors. Organizational culture is assessed using the Organizational Culture Assessment Instrument grounded in the competing values framework. Organizational change perception is measured using an established scale adapted into Turkish with three response dimensions. The paper also reports a rigorous item-level decision process, including the removal of low-loading items and the adjustment of factor structures to preserve validity and reliability. This matters for interpretation because the strength of the conclusions depends on whether leadership, culture, and change perception were measured as distinct constructs rather than overlapping managerial “goodness” factors.
Descriptively, employees reported moderate levels of transformational leadership, moderate endorsement of all four culture dimensions, and a moderate level of organizational change perception overall. Among change perception subdimensions, cognitive response emerged with the highest mean, suggesting that staff are more prepared to think about and appraise change than to experience it emotionally as positive or to fully translate it into sustained behavior. This pattern is consistent with the idea that in high-change environments, staff can intellectually understand the rationale for change while still experiencing emotional ambivalence and behavioral friction, which makes the identification of managerial levers that shift perceptions from cognition to commitment practically significant.
The results support the study’s central claim that transformational leadership substantially predicts employees’ perceptions of organizational change, but that a large share of this relationship operates through culture. Before introducing mediators, transformational leadership shows a strong total effect on organizational change perception (β = 0.614). Once the four culture types are modeled as parallel mediators, the direct effect of transformational leadership drops markedly (β = 0.179), indicating partial mediation rather than full mediation. In practical terms, this means leadership still matters directly, but much of its influence works by shaping the cultural conditions that employees use to interpret whether change is coherent, legitimate, and workable.
Among the mediators, adhocracy culture carries the strongest indirect effect (β = 0.215), followed by clan and hierarchy (each β = 0.078), and market culture (β = 0.062). This hierarchy of mediation effects is theoretically meaningful. Adhocracy culture emphasizes flexibility, innovation, experimentation, and readiness to adapt, which directly aligns with the demands of digital transformation and the process discipline implied by accreditation. If transformational leadership increases the presence of adhocracy-like norms, employees may perceive change as an opportunity for improvement rather than as externally imposed disruption. Clan and hierarchy cultures contribute in smaller but still significant ways, implying that relational cohesion and clear structuring can also support change perception, though they do so less powerfully than an innovation-oriented cultural logic. Market culture has the weakest indirect effect, suggesting that performance and competitiveness signals may help, but they do not substitute for flexibility, learning, and internal alignment in hospitals undergoing complex change.
A second contribution is the study’s contextualization of hospital culture as heterogeneous rather than singular. The finding that hierarchy and market culture show the highest mean levels indicates that the studied hospitals operate with strong control, stability, and performance orientation, which is typical for public healthcare settings. Yet the same hospitals are also undergoing digital and accreditation-driven change that requires innovation and adaptive problem-solving, the very capacities emphasized by adhocracy. The paper highlights a managerial development implication: if hospitals are dominated by hierarchy and market logics, leaders may need to intentionally cultivate adhocracy elements to enhance change readiness. The strategic tension here is that hospitals cannot abandon hierarchy, because patient safety and standardization require it, but they also cannot rely exclusively on hierarchy if they expect staff to experiment, learn new digital workflows, and continuously improve processes.
The practical implications are explicit and actionable. If hospital managers want to improve readiness for change, they should strengthen transformational leadership practices while simultaneously developing cultural conditions that make change psychologically and operationally feasible. In this study’s logic, leadership is the initiator, but culture is the amplifier and transmission system. Particularly, fostering an adhocracy-oriented culture is positioned as a high-leverage target: it is the strongest mediating pathway and therefore the most efficient cultural investment for improving how employees perceive organizational change. The paper also suggests that a comprehensive change management approach should go beyond informing staff and should address participation and emotional dimensions, because cognitive understanding alone does not guarantee positive emotional acceptance or behavioral adoption.
From an originality standpoint, the value is less about introducing new constructs and more about specifying their interplay in a context where both accreditation and digitalization are occurring together. The study contributes by empirically testing mediation via the competing values culture types in Turkish public hospitals that are simultaneously accredited and digitally certified, a setting that is rare enough to be analytically valuable. The results also provide a nuanced view that avoids simplistic prescriptions such as “be transformational and change will succeed.” Instead, the evidence indicates that transformational leadership works partly because it shapes multiple culture dimensions at once, and those dimensions differ in how strongly they translate leadership into change perception. That differentiation is the kind of detail health managers need when deciding where to invest scarce attention and organizational development resources.
Reference: Orhan, M., & Akbulut, Y. (2026). Examining the relationship between transformational leadership, organizational culture and organizational change perception in a hospital setting: a structural equation modeling approach. Leadership in Health Services, 1-13.
Mini dictionary
Transformational leadership refers to a leadership style in which managers influence employees by creating meaning, articulating a compelling vision, empowering staff, and stimulating commitment beyond routine compliance, thereby shaping motivation and readiness for organizational initiatives.
Organizational culture describes the shared values, assumptions, and norms that guide how work is understood and executed in an organization, functioning as the internal logic that shapes what employees perceive as legitimate, risky, or worthwhile during change.
Organizational change perception is the way employees interpret and respond to change as a process, typically expressed through cognitive appraisals, emotional reactions, and behavioral tendencies that collectively influence whether change is resisted, tolerated, or embraced.
Adhocracy culture is a culture type emphasizing flexibility, innovation, experimentation, and adaptability, making it particularly relevant to environments where new technologies and evolving standards require continuous learning and rapid problem solving.
Hierarchy culture is a culture type emphasizing stability, formal rules, clear procedures, and control, which can support standardization and safety but may constrain agility if it becomes the dominant response to every change demand.
Clan culture is a culture type emphasizing cohesion, trust, participation, and a family-like climate, which can facilitate change by strengthening psychological safety and peer support during transitions.
Parallel mediation in SEM refers to a modeling approach where multiple mediators are tested simultaneously as distinct pathways linking an independent variable to an outcome, allowing researchers to compare which mechanisms carry more of the total effect.