Why Nursing Leadership Drives Safety

Introduction
Although senior management and public policy are also integral to the creation and maintenance of a culture of safety in healthcare organizations, nursing leadership is the most critical component in promoting desired patient outcomes. The importance of safety culture is given a tremendous amount of coverage in nursing literature and in daily discourse, but “nurse leaders continue to struggle to achieve such a culture in today's complex and fast-paced healthcare environment,” (Sammer & James, 2011, p. 3). Until recently, gaps in the literature have stymied efforts to improve patient safety via the implementation of a comprehensive safety culture in the healthcare organization. In particular, there had been gaps “in relation to knowledge on the extent and nature of the role of nurses in patient safety improvement,” (Richardson, 2010, p. 12). Recent research has helped to clarify the specific aspects of nursing leadership that can promote patient safety and improve patient outcomes. The primary factors influencing patient safety and patient outcomes include mentoring programs, improving quality improvement processes through innovative practices, empowering nurses via transformational leadership, and non-punitive medical error reporting. Additional factors driving patient safety include leadership in a more general sense, evidence-based practice at all levels of organizational behavior, and also “teamwork, communication, and a learning, just, and patient-centered culture,” (Sammer & James, 2011, p. 3). Creating a culture of safety is ultimately an organization-wide systemic issue.
Transformational Leadership
Empowerment and Support
In a general sense, “nursing leadership is pivotal to providing high-quality patient care and ensuring favorable organizational outcomes,” (Boamah, Laschinger, Wong, et al., 2017, p. 1). However, research consistently reveals the efficacy of transformational leadership specifically on promoting patient safety and improving patient outcomes. Transformational leadership has been demonstrated to be a “key to achieving the sustainable effects of mentoring programs that are rooted deeply in organizational culture,” (Bally, 2007, p. 143). When empowering nurses in a transformational leadership context, nurses are able to make strategic decisions that improve patient outcomes through the implementation of evidence-based safety practices. Nurses are also empowered to make decisions independently as well as in a team-based or collaborative environment, one in which nurses’ input, feedback, and even dissent promotes patient safety. To promote nurse empowerment, leaders at all levels of the organization need to cultivate the skills of transformational leadership. “Managers who demonstrate transformational leadership in the workplace have greater potential to create environments that support professional nursing practice that promote high-quality patient care,” (Boamah, Laschinger, Wong, et al., 2017, p. 1). Transformational leadership creates a supportive environment in which nurses are unafraid to report their own or colleague’s errors, and to share information openly with leaders as well as patients.
In fact, a non-punitive approach to nurse leadership is critical, and embedded in the model of transformational leadership. Kim, An, Kim, et al. (2007) conducted a survey of 886 nurses in Korea and “found that the majority of nurses were not comfortable reporting errors or communicating concerns about safety issues,” (p. 827). The results of the Korean study imply that “patient safety could be improved in a non-punitive culture where individuals can openly discuss medical errors and potential hazards,” (p. 827). Similarly, Vaismoradi, Griffiths, Turunen, et al. (2016) found the “creation of a supportive culture” to be integral in promoting patient safety and improving patient outcomes (p. 970). A non-punitive approach can also be combined with the promotion of nurse competencies through mentoring and formal training or professional development. “A focus on the role of nurse educators and mentors in the development of students’ abilities” has also been linked to the promotion of a culture of safety and subsequently, improved patient outcomes (Vaismoradi, Griffiths, Turunen, et al., 2016, p. 970).
Interface Between Transformational Leadership and Culture
Empirical studies substantiate the importance of transformational leadership in the healthcare environment, when patient safety and patient outcomes are the ultimate goals. For example, Provonost, Weast, Holzmuller, et al. (2003) conducted “the first large scale” study that measures the “institutional culture of safety and then design improvements in health care,” and the researchers found that “strategic planning of patient safety needs enhancement,” (p. 405). Therefore, transformational leadership does need to be combined with top-down management-driven models of safety that include quality assurance procedures. Transformational leadership was also shown to be statistically more effective at improving all patient safety measures when compared with other leadership styles. For example, “transformational leadership style was demonstrated as a positive contributor to safety climate, whereas laissez-faire leadership style was shown to negatively contribute to unit socialization and a culture of blame,” (Merrill, 2015, p. 319). Transformational leadership also has indirect effects on promoting a culture of safety because of the way empowering nurses improves job satisfaction, reduces burnout, and promotes patient-centric care. Boamah, Laschinger, Wong, et al. (2017) found “transformational leadership indirectly influences nurses' job satisfaction and prevalence of adverse patient outcomes through workplace empowerment,” (p. 1).
Shared Values in a Climate of Safety
Transformational leadership also facilitates the learning organization model, which is also linked to improve patient and safety outcomes. A learning organization is open and willing to change, while also empowering all members of the healthcare team to contribute ideas and to make necessary changes in a supportive, patient-centered environment. “Adopting a learning organization approach helps promote a patient safety culture,” (Callahan & Ruchlin, 2003, p. 296). There are two additional components of transformational leadership that promote patient safety: innovation and ethics. “Transformational leadership has indirect effects on innovation behavior via the mediation of patient safety climate and innovation climate,” (Weng, Huang, Chen, et al., 2013, p. 427). In one study by Feng, Bobay & Weiss (2008), researchers found that nurses’ shared values, beliefs and behavioral norms towards patient safety were identified as the overarching dimensions of the patient safety culture,” (p. 310). Therefore, it becomes critical for all nurses to share responsibility in creating the normative culture of safety.
Research also links a culture of safety to a culture of innovation, in which nurses are empowered to improve patient outcomes: “Transformational leadership has indirect effects on innovation behavior via the mediation of patient safety climate and innovation climate,” (Weng, Huang, Chen, et al., 2013, p. 427). Also, a transformational leadership approach that encourages innovation has been linked to an “enhancement of students’ creativity, motivation and ethical behaviour,” (Vaismoradi, Griffiths, Turunen, et al., 2016, p. 970). There is a clear need for “shared responsibility” for promoting safety (Lyndon, Johnson, Bingham, et al., 2015, p. 341). The shared responsibility begins with leadership, as “ organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality,” (Lyndon, Johnson, Bingham, et al., 2015, p. 341). Transformational leaders committed to a culture of safety also need to create formal systems in place whereby quality assurance, quality improvement, and environmental standards are strictly maintained. Similarly, leaders need to maintain evidence-based practice standards among staff.
Environmental, Structural, and Competency Factors
As important as leadership and organizational culture alone can be for creating and maintaining the culture of safety in a healthcare organization, environmental and structural variables are also critical for patient outcome goals. “The most commonly reported threats to patient safety in the critical care practice environment reported by all provider stakeholder groups include patient acuity, inadequate physical environment, and insufficient human and technological resources,” (Tregunno, 2009, p. 1). Therefore, leadership needs to pay close attention to the physical environment including equipment maintenance and overall nurse competencies. Armstrong & Laschinger (2006) also link the quality and features of the practice environment with a culture of safety.
Nurse competency and the implementation of evidence-based practice are also important for promoting patient safety and patient outcomes. Yet competencies also need to coincide with cultural factors, driven by leadership. Vogus & Sutcliffe (2007b) found “safety organizing plays a key role in improving patient safety on hospital nursing units especially when bundled with other organizational components of a safety supportive system,” (p. 997). In critical care environments, a culture of safety can be experienced as as a pervasive and uncomfortable tension between patient safety threats that are linked to provider knowledge and experience, and those linked to workplace conditions,” (Tregunno, 2009, p. 1). Thus nurse leaders need to come up with strategic ways of managing environmental variables and human factors to reduce medical errors.
Processes and Formal Quality Assurance
Within a healthcare organization that is dedicated to patient safety, leaders need to formally address ideal outcomes within an evidence-based performance outcomes framework. McFadden & Gowen (2015) found that using formal quality improvement controls will “effectively enhance process quality in hospitals, and patient safety climate to improve patient safety outcomes,” (p. 24). The reasons for formal quality assurance and quality improvement procedures include both actual and perceptual changes. Nurse perception of leadership enhances trust and perceived leadership legitimacy. “Nurses who had more years of experience and were working in teaching hospitals had more perception of patient safety culture,” (Ammouri, Tailakh, Muliira, et al., 2014, p. 102). Moreover, “nurses who perceived more supervisor or manager expectations, feedback and communications about errors, teamwork across hospital units, and hospital handoffs and transitions had more overall perception of patient safety,” (Ammouri, Tailakh, Muliira, et al., 2014, p. 102). Ammouri, Tailakh, Miliira, et al. 92014) also found that nurses who had formal feedback and communications systems in place for error reporting were more likely to report errors than those without such structural supports or formal procedures guiding their behaviors.
In other words, formal rules and regulations are important for the overall safety culture. The Joint Commission (2017) found that the reverse is also true: “insufficient support of patient safety event reporting, lack of feedback or response to staff and others who report safety vulnerabilities,” is linked to increased staff burnout as well as to increases in errors (p. 1). Other problems observed in poorly performing institutions included the intimidation of staff who report adverse events, refusing to consistently prioritize and implement safety recommendations, and not addressing staff burnout,” (The Joint Commission, 2017, p. 1). Nurse burnout has been consistently reported as an issue in patient safety. Research also points to the concept of “emotional labor,” as well as long working hours that are negatively correlated with a safety climate (Liang, Tang, Wang, et al., 2016, p. 3068).
Formal Assessments
Nurse leaders need to “identify latent hazards and weaknesses” within the organization including its procedures, malfunctioning equipment, lack of competencies, burnout, and other issues (The Joint Commission, 2017, p. 1). The best way to address shortcomings is through ongoing formal assessments, which can quantify problems and point the way towards effective and evidence-based solutions. Some of the known examples of “latent hazards and weaknesses” within the organizational environment, structure, and culture include “poor design, lack of supervision, and manufacturing or maintenance defects,” (The Joint Commission, 2017, p. 1). Nurse leaders also understand that in addition to the environmental and technological issues that need to be addressed to promote patient safety, the organizational culture needs to be supportive because “humans make mistakes,” (The Joint Commission, 2017, p. 1). Nurse leaders need to be supportive and empowering through transformational leadership, while also being attentive, aware of shortcomings, and willing to change to make systematic improvements.
Nurses can contribute to a climate of safety in an organization with a culture of safety. Vogus & Sutcliffe (2007a) developed the Safety Organizing Scale, a self-report method whereby nurses could comment on safety culture in their organizations; it “provides meaningful, behavioral insight into the enactment of a safety culture, but because of the association between SOS scores and reported medication errors and patient falls,” for example, (p. 46). The self-reporting mechanism also provides information that may be “useful to registered nurses, nurse managers, hospital administrators, and governmental agencies,” (Vogus & Sutcliffe, 2007a, p. 46). Using formal instruments to measure compliance and safety outcomes can therefore be tremendously helpful for a learning organization to achieve its safety and patient outcomes objectives.
Communication
Effective communication protocols, both informal and formal, are also leadership-driven methods for promoting safety. “Effective, patient?centered communication facilitates interception and correction of potentially harmful conditions and errors,” (Lyndon, Johnson, Bingham, et al., 2015, p. 341). Within the transformational leadership framework, communication with nurses and among nurses is empowering and fosters trust, honesty, and integrity. Formal feedback mechanisms are also requisite for promoting a culture of safety. “Nurses who perceived more supervisor or manager expectations, feedback and communications about errors, teamwork across hospital units, and hospital handoffs and transitions had more overall perception of patient safety,” (Ammouri, Tailakh, Muliira, et al., 2014, p. 102). Therefore, nurse leaders who communicate their expectations clearly, have clearly stated procedural goals and objectives, and who have in place non-punitive error reporting systems will promote a climate of safety in their organization.
External communications are also necessary, as healthcare organizations increasingly rely on strategic partnerships and team-based medical care. Cultural competency, or the ability for nurses to communication across different cultures to remove barriers to understanding, also helps promote safety because of the way informing patients about their status, medications, and other information can improve patient outcomes. Thompson, Navarra & Antonson (2005) identify four domains of nursing leadership that provide a model for promoting patient outcomes through a culture of safety: leadership competencies, culture, shared leadership, and external partnerships. Sharing responsibility across multiple strategic partnerships means relying on information sharing, but often nurse leaders will be powerless to influence how other organizations operate. Communicating expectations and holding team members accountable, nurse leaders continue to promote safety as an overall ethical standard.
Conclusion
Nursing leadership at all levels of an organization is of critical importance in driving safety cultures. A fantastic and ever-changing area of inquiry, the interface between nurse leadership, organizational culture, and measurable patient outcomes hinges on creating learning organizations. Learning organizations are responsive to environmental, technological, and legislative trends, as well as to emerging literature on human resources and organizational behavior.
Nurses who are empowered and supported by their colleagues and supervisors will be more adept at detecting errors, and perhaps most importantly, more willing to report errors. Similarly, nurses who are encouraged to improve core competencies throughout their career via organizational policies that promote professional growth will also help increase the standards of performance at all levels of the organization. Nurse leaders in senior management need to create top-down policies and procedures, with clearly explicated safety guidelines and the roles and responsibilities each nurse plays in implementing them. Those safety regulations and guidelines are specific, evidence, based, and yet open to question and creative interpretation to accommodate for situational constraints. Nurse leaders at every level of the organization also have formal and informal procedures in place whereby nurses can communicate concerns in safe and non-punitive environment. Finally, leadership at all levels of the healthcare organization needs to remain cognizant of the role that nurse job satisfaction and reducing burnout has on safety. Empowerment, communications, and shared values in a learning environment are both bottom-up and top-down factors that enhance patient safety and improve patient outcomes in meaningful and measurable ways.








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