Nursing Leadership and Patient Safety Culture in Healthcare

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 receives 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 stymied efforts to improve patient safety via the implementation of a comprehensive safety culture in healthcare organizations. 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 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 and Nurse Empowerment

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). Research consistently reveals the efficacy of transformational leadership specifically in 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 nurses are empowered within a transformational leadership context, they 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 team-based or collaborative environments — ones in which nurses' input, feedback, and even dissent promote patient safety. To foster 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 and 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 colleagues' errors, and to share information openly with leaders as well as patients.

A non-punitive approach to nurse leadership is critical and is 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 that 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, to improved patient outcomes (Vaismoradi, Griffiths, Turunen, et al., 2016, p. 970).

Empirical studies substantiate the importance of transformational leadership in the healthcare environment when patient safety and patient outcomes are the ultimate goals. Pronovost, Weast, Holzmuller, et al. (2003) conducted "the first large-scale" study measuring the "institutional culture of safety" in order to "design improvements in health care," and the researchers found that "strategic planning of patient safety needs enhancement" (p. 405). Therefore, transformational leadership needs 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 through the way in which empowering nurses improves job satisfaction, reduces burnout, and promotes patient-centric care. Boamah, Laschinger, Wong, et al. (2017) found that "transformational leadership indirectly influences nurses' job satisfaction and prevalence of adverse patient outcomes through workplace empowerment" (p. 1).

Transformational leadership also facilitates the learning organization model, which is likewise linked to improved 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 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). Two additional components of transformational leadership that promote patient safety are 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 a study by Feng, Bobay, and 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). It therefore becomes critical for all nurses to share responsibility in creating the normative culture of safety.

Shared Values and a Culture of Safety

Research also links a culture of safety to a culture of innovation in which nurses are empowered to improve patient outcomes. 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). That 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 whereby quality assurance, quality improvement, and environmental standards are strictly maintained. Similarly, leaders need to uphold evidence-based practice standards among staff.

As important as leadership and organizational culture can be for creating and maintaining a culture of safety in a healthcare organization, environmental and structural variables are also critical for achieving 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 and Laschinger (2006) also link the quality and features of the practice environment to 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 must coincide with cultural factors driven by leadership. Vogus and Sutcliffe (2007b) found that "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 "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). Nurse leaders therefore need to develop strategic ways of managing environmental variables and human factors to reduce medical errors.

Conclusion

Nursing leadership at all levels of an organization is of critical importance in driving safety cultures. A dynamic 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.