LMCP
D I S C U R S I V E P A P E R
The nexus of nursing leadership and a culture of safer patient care
Melanie Murray RN, Doctoral Candidate1 | Deborah Sundin PhD, Senior Lecturer1 |
Vicki Cope PhD, Associate Professor Nursing, Academic Chair2
1School of Nursing and Midwifery, Edith
Cowan University, Joondalup, WA, Australia
2School of Health Professions, Murdoch
University, Murdoch, WA, Australia
Correspondence
Melanie Murray, School of Nursing and
Midwifery, Edith Cowan University,
Joondalup, WA, Australia.
Email: mmurray7@our.ecu.edu.au
Aims and objectives: To explore the connection between +6 nursing leadership and
enhanced patient safety.
Background: Critical reports from the Institute of Medicine in 1999 and Francis QC
report of 2013 indicate that healthcare organisations, inclusive of nursing leadership,
were remiss or inconsistent in fostering a culture of safety. The factors required to
foster organisational safety culture include supportive leadership, effective commu-
nication, an orientation programme and ongoing training, appropriate staffing, open
communication regarding errors, compliance to policy and procedure, and environ-
mental safety and security. As nurses have the highest patient interaction, and
leadership is discernible at all levels of nursing, nurse leaders are the nexus to influ-
encing organisational culture towards safer practices.
Design: The position of this article was to explore the need to form a nexus
between safety culture and leadership for the provision of safe care.
Conclusions: Safety is crucial in health care for patient safety and patient outcomes.
A culture of safety has been exposed as a major influence on patient safety prac-
tices, heavily influenced by leadership behaviours. The relationship between leader-
ship and safety plays a pivotal role in creating positive safety outcomes for patient
care. A safe culture is one nurtured by effective leadership.
Relevance to practice: Patient safety is the responsibility of all healthcare workers,
from the highest executive to the bedside nurse, thus effective leadership through-
out all levels is essential in engaging staff to provide high quality care for the best
possible patient outcomes.
K E YWORD S
health care, leadership, patient safety, safety culture
1 | INTRODUCTION
Patient safety culture is reflected in the beliefs, attitudes, percep-
tions, values and patterns of behaviour of an organisation and its
employees towards safety (Bowie, 2010; Muls et al., 2015). As
recently evidenced in such investigations as the Mid-Staffordshire
Trust enquiry (Francis, 2013), healthcare environments have been
acknowledged as high-risk and a lack of a safety culture have major
effects on patient outcomes. Alternatively, a positive safety culture
in health care is evidenced by visibility of leaders and credible sup-
port for patient safety initiatives (Agnew, Flin, & Reid, 2012; Castel,
Ginsburg, Zaheer, & Tamim, 2015). Avoidance of adverse events
requires a system-wide approach as it is recognised that errors are
the result of failures related to “. . .management decisions and organ-
isational processes” (Auer, Schwendimann, Koch, De Geest, &
Ausserhofer, 2014, p. 23; Kaufman & McCaughan, 2013). To
Accepted: 25 July 2017
DOI: 10.1111/jocn.13980
J Clin Nurs. 2018;27:1287–1293. wileyonlinelibrary.com/journal/jocn © 2017 John Wiley & Sons Ltd | 1287
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overcome system faults, setting patient safety as an organisational
priority assists in fostering a culture of safety (Auer et al., 2014). A
strong safety culture will use failings to adapt work practices aiming
to improve and enhance patient care, thus increasing positive out-
comes (Bowie, 2010). Development of a safety culture relies upon
engagement at all levels, communication between executive and unit
levels, and trust in organisational leaders and management (Ammouri,
Tailakh, Muliira, Geethakrishnan, & Al Kindi, 2015; Auer et al.,
2014).
Safety culture has only recently been emphasised within health
care, after having been prominent in safety critical industries such as
aviation and the military for many years. A positive safety culture
does not just happen, and it requires the input and alignment of
quality and organisational properties. These properties have been
identified as: teamwork, evidence-based practice, communication,
ongoing education, a just culture, leadership and patient-centred care
(Reid & Dennison, 2011; Sammer, Lykens, Singh, Mains, & Lackan,
2010). A culture of patient safety within an organisation requires
support from all parties, especially organisational leaders. The Mid-
Staffordshire public enquiry exposed a lack of basic patient care, and
a negative organisational culture fostered by a focus on systems
statistics and reports rather than patient experiences and outcomes
(Francis, 2013). A positive safety culture, on the other hand, provides
a platform on which to base patient-centred care with safe care
delivery, shared values, zero tolerance for substandard care, empow-
erment of front-line staff, recognition of staff for their contributions
and professional responsibility described as foundations for patient-
centred care (Francis, 2013; Muls et al., 2015).
Patient safety has been on the global healthcare agenda since
the Institute of Medicine released its report “To Err is Human”
where medical errors were highlighted as taking more lives than
motor vehicle accidents, breast cancer and AIDS (Kohn, Corrigan, &
Donaldson, 2000). This sparked several initiatives from the World
Health Organization (WHO) such as the perioperative Surgical Safety
Checklist and the introduction of Hand Hygiene programmes to
globally improve patient safety (WHO, 2009). A major systemic influ-
ence on patient care, and thus patient safety, is nursing leadership
(Agnew et al., 2012; Auer et al., 2014; Cummings et al., 2010; Dig-
nam et al., 2011; O’Connor & Carlson, 2016; Vaismoradi, Bondas,
Salsali, Jasper, & Turunen, 2012). As nurses have the highest patient
interaction, nurse leaders are in the best position to influence organi-
sational culture towards safer practices (Hendricks, Cope, & Baum,
2015; Vaismoradi et al., 2012).
2 | METHODS
An integrative review of research literature was undertaken to
develop an understanding of leadership in health care and its influ-
ence on patient safety and safety culture. Inclusion and exclusion cri-
teria were determined to provide consistency and rigour to the
literature review. Articles were included if they were written in Eng-
lish; full-text; peer-reviewed research published between 2010 and
2016. The articles include content on both leadership and patient
safety. Papers were excluded if they were not published in English
and did not meet the inclusion criteria.
The initial search of the databases identified 905 articles, of
which 298 articles met inclusion criteria based on their titles. A
review of the keywords in these 298 articles led to elimination of a
further 194 articles, leaving 104 articles for initial review. Fifty-four
were discarded following review of their abstracts. The initial selec-
tion of articles yielded 50 articles for inclusion and following review,
a further 10 articles were excluded as there was no discussion or
findings correlating leadership to patient safety or safety culture,
leaving 30 for inclusion.
Themes developed during the review of the literature based on
the influences on safety culture in health care. These themes have
been labelled “leadership and employee engagement and empower-
ment,” “barriers to a safety culture,” and “leadership styles and
patient outcomes.” Before discussion of these themes, a description
of leadership styles prominent in nursing is warranted.
2.1 | Leadership styles
Leadership theories have been studied and developed throughout
history starting with the Great Man Theory of the 1800s to the
Army Leadership model of 2007 (Ledlow & Coppola, 2014). These
theories have seen many styles of leadership emerge, although not
all leadership styles suit all situations. Styles of leadership explain
how leaders engage with others. Leadership may be categorised
under two main style types: relational and task-oriented (Cummings,
2012; Cummings et al., 2010). The leadership styles prominent in
healthcare literature are transformational and transactional leader-
ship. In-depth discussion on leadership theories and styles is beyond
the scope of this paper; however, a short description is warranted.
Transformational leadership theory was developed in the 1970s
by Burns (Burns, 1978) and has recently been explored throughout
nursing literature. Transformational leadership is a relational leader-
ship style adopted by Magnet hospitals (Brewer et al., 2016) to lead
charge in developing and maintaining standards of excellence in
patient safety and patient outcomes. This style of leadership is asso-
ciated with positive patient outcomes resulting from a blameless
safety culture (Lievens & Vlerick, 2013; McFadden, Stock, & Gowen,
2015; Merrill, 2015). A blameless safety culture, or a just culture, is
What does this paper contribute to the wider
global clinical community?
• Leadership engagement enhances patient safety through
positive safety culture
• Leadership education is important for the support of
emerging nurse leaders
• Adopting an organisation wide blame-free philosophy
breaks down barriers to a safety culture
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a nonpunitive environment where inadvertent actions are used as a
stepping stone to improve practice, but where reckless behaviour
will not be tolerated (Jarrett, 2017).
The characteristics of a transformational leader include the ability
to engage, motivate, inspire and empower followers to aim above and
beyond their own boundaries to achieve a shared vision or organisa-
tional goal. Leaders are visible; they set clear expectations and pro-
mote open multidisciplinary communication; and they see errors as an
opportunity for improvement (McFadden et al., 2015; Merrill, 2015;
O’Connor & Carlson, 2016). Transformational leaders invoke change
and demonstrate emotional intelligence, consult with their followers
before making decisions and share the load (Cope & Murray, 2017;
Doody & Doody, 2012; Giltinane, 2013). This style of leadership fos-
ters a safety culture within an organisation through the development
of trust and a just, blame-free environment (Merrill, 2015; Vogelsme-
ier, Scott-Cawiezell, Miller, & Griffith, 2010). Transformational leaders
value their followers opinions, respect their experience affirm their
nurse colleagues ideas and involve them in decision-making (Sherman,
2012). In large organisations, there may be pockets of excellence in
units or areas where the leaders have an exceptional following; how-
ever, this may not be represented across an organisation. Similarities
exist in transactional leaders described to follow.
Transactional leadership, a task-oriented leadership style, uses
rewards to motivate followers to achieve goals (Ledlow & Coppola,
2014). This in turn can have a positive influence on follower’s satis-
faction levels. This leadership style is very effective when decisions
need to be made with haste, such as during medical crises, however,
may have negative effects on patient outcomes as it may reinforce
task-based behaviours in nurses which lies in contrast to holistic
nursing care (Cope & Murray, 2017; Giltinane, 2013). Both transfor-
mational and transactional styles of leadership use forms of motiva-
tion to engage staff or followers.
2.2 | Leadership and employee engagement and empowerment
Engagement has been defined by Schaufeli, Matinez, Pinto, Salanova
and Bakker (cited in Bargagliotti, 2012, p. 1416) as a “. . .positive, ful-
filling work-related state of mind”. Nurses who are engaged have
better patient and organisational outcomes and leadership engage-
ment is influential in bedside nurse performance (Brady Germain &
Cummings, 2010; Day, 2014). Nurse leaders who set clear guideli-
nes, share their vision and lead by example have greater employee
engagement associated with increased performance from bedside
nurses, which is important for safe and innovative practice (Brady
Germain & Cummings, 2010). Senior nurse leaders may use recogni-
tion of good practice to motivate and empower bedside nurses to
improve quality of care across the board (Haycock-Stuart & Kean,
2012). Leadership engagement at the unit level has significant posi-
tive effects on the reporting of errors and adverse events as leaders
who engage their staff create an open communication environment
where there is no fear of repercussions for reporting errors (Castel
et al., 2015).
Employee engagement by nurse leaders assists in developing
trust in leaders’. Trust boosts safety culture, and visibility of leaders
fosters trust. With the establishment of trust, organisational staff
believe concerns will be heard and that the necessary patient safety
changes will occur. Open communication channels developed
through trust leads to a nonblame culture (Vogelsmeier et al., 2010).
Studies suggest that organisations that have created a nonblame
safety culture have better patient outcomes (O’Connor & Carlson,
2016). These outcomes occur when leaders create an environment
where staff are encouraged to report errors, adverse events, near
misses and unsafe practices so system changes can be made (O’Con-
nor & Carlson, 2016; Sammer et al., 2010). In a culture of safety,
staff are also enabled to seek help, without the threat of derision,
but by knowing that they can voice their need for assistance to
avoid possible harm (Squires, Tourangeau, Spence Laschinger, &
Doran, 2010).
Reports such as Francis (2013) revealed poor work environments
that had negative impacts on patient outcomes. Such environments
develop in the presence of dissatisfied nurses who may be suffering
burnout or emotional exhaustion from ineffective leadership either
at a unit level or throughout an organisation (Daly, Jackson, Mannix,
Davidson, & Hutchinson, 2014). With burnout, emotional exhaustion,
and dissatisfaction, comes high attrition. This may be alleviated in
part through leadership engagement of bedside nurses who realise
the importance of their own clinical work and that of the quality
agenda of the organisation, thus creating positive work environments
(Daly et al., 2014).
Empowerment of staff through leadership engagement is a key
variable in job satisfaction, organisational commitment and intention
to stay (Cowden & Cummings, 2015). Intention to stay is an impor-
tant consideration for healthcare organisations the world over with
Australia predicting a nursing shortfall of approximately 109 000
within the next 10 years (Roche, Duffield, Dimitrelis, & Frew, 2015).
Through the creation of positive work environments, support for
bedside nurses and active promotion of organisational goals and
visions to encourage organisational commitment, transformational
leaders play a direct role in nursing job satisfaction and intention to
stay (Brewer et al., 2016; Roche et al., 2015).
Clinical nurse leaders are essential for ongoing quality of safe
patient care (Hendricks et al., 2015). Organisations need to invest in
leadership development as part of their succession planning. Glob-
ally, there is a push for nurses to receive leadership education at
undergraduate level, at entry level to the profession and through
ongoing leadership programmes within their work environments so
as to grow and nurture leaders at all levels for succession planning
(Sherman & Pross, 2010; Squires et al., 2010). Shared governance
frameworks have placed patient safety as the responsibility of all
healthcare workers and serve to empower staff to participate in
organisational decision-making to enhance patient outcomes (Kut-
ney-Lee et al., 2016). These frameworks also promote leadership
education and development programmes for all nursing levels,
including new graduate nurses (Hendricks et al., 2015). Such pro-
grammes have been evaluated as being beneficial as nurses learn
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necessary leadership skills, gain awareness of the political and organ-
isational needs that promote leader and organisational engagement,
build self-awareness and become empowered in their practice which
has the flow on effect of empowering others. These enhanced skills
empower nurses, especially the new graduate nurse, to autono-
mously make decisions at the bedside to maintain high levels of safe
patient care (Hendricks et al., 2015). Fresh perspectives on quality
care and safety challenges require engaged leadership and engaged
employees.
The employee engagement initiative of Leadership WalkRounds
has been introduced in many hospitals worldwide. Leadership Walk-
Rounds (WR) involve senior leaders and organisational executives
engaging with bedside nurses to discuss patient safety concerns
(Rotteau, Shojania, & Webster, 2014; Sexton et al., 2014). The Walk-
Round provides visibility of organisational or senior clinical leaders
creating opportunities for bedside staff to raise patient safety con-
cerns to the executive level (Rotteau et al., 2014; Sexton et al.,
2014). WRs have been documented as having a positive effect on
patient safety outcomes with personal feedback to those bedside
nurses raising concerns (Sexton et al., 2014). Alternatively, the WR
can potentially provide a barrier to safety if competing goals are not
recognised and mixed messages are sent. WalkRounds may expose a
disparity in perceptions between bedside nurses and hospital or
organisational leaders’ opinions of the most critical issues to be con-
sidered regarding safety practices for positive patient outcomes and
those perceptions of hospital or organisational leaders (Haycock-
Stuart & Kean, 2012; Rotteau et al., 2014; Sexton et al., 2014).
Hospital leaders may well steer conversations to issues of concern in
their remit while missing or ignoring vital issues at the bedside.
A further opportunity for organisational leaders to engage with
nursing staff is through the Chief Nursing Officer (CNO). CNOs are
leaders within healthcare organisations and in the best position to
be a nexus between bedside nurses and the organisation executive.
Having a CNO within the organisational leadership team assists in
the engagement of bedside nurses through leadership visibility and
promotion of the quality and safety agenda, however, nurses are
rarely represented on governing boards where decisions are made
on policy and strategic priorities (Disch, Dreher, Davidson, Sinioris, &
Wainio, 2011). As hospital boards are typically physician heavy,
there is an imbalance in strategic priorities in that perceptions of
safety and what constitutes an error may be different between
nurses and physicians which may potentiate breakdowns in commu-
nication and mistrust in the leaders (Castel et al., 2015; Vogelsmeier
et al., 2010). Healthcare organisations globally are promoting safety
culture through accreditation schemes, in some cases redesigning
work environments to support safety culture changes (Ammouri
et al., 2015).
Many hospitals, primarily in the United States of America (USA),
but also in Australia, Canada, Lebanon and Saudi Arabia have gained
Magnet accreditation through the American Nurses Credentialing
Center (ANCC) (American Nurses Credentialing Center, 2017). Mag-
net accreditation status is awarded to facilities who implement and
maintain exemplary health care through the five forces of
magnetism: transformational leadership; structural empowerment;
exemplary professional practice; new knowledge, innovation and
improvements; and empirical quality results (American Nurses Cre-
dentialing Center, 2017). This Magnet recognition framework pro-
motes exemplary nursing care through a positive workplace culture.
The framework provides a basis on which to build an enhanced set-
ting that recruits and retains highly qualified staff and through strong
leadership maintains high staff satisfaction levels that have been pro-
ven to flow on to decreased patient mortality rates (Aiken et al.,
2011; Moss, Mitchell, & Casey, 2017). High-quality work environ-
ments are the building blocks on which a culture of safety can be
built; however, they cannot occur nor be sustained unless nurse
leaders acknowledge their importance, and wholeheartedly endeav-
our to continue the work required to support them.
2.3 | Barriers to a safety culture
Safety culture is influenced by several factors both positive and
negative. Blame has been recognised as a negative influence on
patient safety and linked to under reporting of errors (Ammouri
et al., 2015; Castel et al., 2015; Kaufman & McCaughan, 2013;
O’Connor & Carlson, 2016 Vogelsmeier et al., 2010; Zaheer, Gins-
burg, Chuang, & Grace, 2015). While reporting systems are present
in many organisations, a culture that does not foster safety initia-
tives, or not seen to be acting on reports, leads to distrust in the
system by bedside nurses (Zaheer et al., 2015). Fears of recrimina-
tion through reporting voiced by bedside nurses include the follow-
ing: disciplinary action, limited career advancement, and retaliation
affecting livelihood (Castel et al., 2015; Kaufman & McCaughan,
2013). A culture of blame may also stem from a major disparity in
perceptions between organisational leaders who “. . .declare patient
safety as an organisational priority” (Vogelsmeier et al., 2010, p.
288) and bedside nurses who “. . .continue to report concerns about
actual safety practices and priorities” yet nothing gets done
(Vogelsmeier et al., 2010, p. 288).
Disempowerment of health professionals has been evident in
health care in recent years due to relentless organisational change
where the focus has strayed from the patient (Dignam et al., 2011).
This was evident in the Francis report (2013) where it was testified
that bedside nurses in the Mid-Staffordshire NHS Foundation Trust
were not engaged and not empowered to provide safe and appropri-
ate care to patients as it was not seen as a priority from organisa-
tional leaders. Nurse leaders have also expressed frustration in being
able to keep up-to-date with research and evidence-based practice
to best support a safety environment and have requested more
ongoing education concerning clinical care, conflict management but
also specifically on leadership (Sherman, Schwarzkopf, & Kiger,
2011).
Organisational changes have led to an increase in administrative
duties for nurse leaders giving them less time to provide clinical
leadership to bedside nurses (Brady Germain & Cummings, 2010;
Dignam et al., 2011). These increased administrative tasks decrease
leader visibility to bedside nurses and hamper channels for reporting
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safety concerns or errors. This may also lead to decreased patient
safety initiatives from the bedside (Dignam et al., 2011).
Inadequate or inappropriate leadership education has also been
recognised as a barrier to nurse’s acceptance of leadership roles
(Enterkin, Robb, & McLaren, 2013; Grindel, 2016). Recruitment to
nurse leader positions is, and has been difficult, due to inadequate
succession planning or preparation and development of bedside
nurses through leadership education (Enterkin et al., 2013; Grindel,
2016). In some instances, this is due to the leader role taking on
increased management and administrative responsibilities and the
bedside nurses being aware of same (Enterkin et al., 2013). Effective
organisational leadership communications organisational goals and
visions (Enterkin et al., 2013). When this is not happening, engage-
ment and recruitment of bedside nurses to leadership roles is further
hampered. Engaging bedside nurses, creating awareness of leader-
ship roles, offering leadership education or supporting staff who
enrol in leadership courses, recognising clinical expertise and
supporting new nursing graduates will improve recruitment into lead-
ership education programmes and to consider leadership roles (Grin-
del, 2016).
Bedside nurses have been reported as believing that the quality
of patient care is dependent on the individual nurse delivering the
care, whereas nurse leaders believe leadership impacts the quality of
care by driving the quality agenda through policy development and
leadership from the executive perspective (Haycock-Stuart & Kean,
2012).
2.4 | Leadership styles and patient outcomes
Nurse leadership may have both positive and negative impacts on
the work environment, depending upon the leadership style and atti-
tudes of the leader. A leader need not be a manager, a person of
power or someone in the organisational hierarchy, although leaders
in these areas will be highly influential on organisational culture
(Daly et al., 2014).
Care settings having strong leadership, with satisfactory staff-
ing levels, multidisciplinary collaboration and empowerment to con-
tribute to policy development, have decreased incidence of
adverse events such as medication errors, healthcare acquired
infections, complaints related to care and falls (Wong & Gial-
lonardo, 2013). Patient safety is also concomitant to the nursing
work environment and the influence of leadership on the workings
of this care setting (Squires et al., 2010). Poor leadership beha-
viours, such as those of the laissez-faire leader: no leadership, or
ineffective leadership impact absenteeism, stress, emotional
exhaustion and intention to leave (Cope & Murray, 2017; Merrill,
2015). These factors have a significant effect on the quality of
care provided by bedside nurses and on patient safety (Squires
et al., 2010).
Creating safe care environments requires nurse leaders to “listen
and learn” (Squires et al., 2010, p. 916) and involve employees in
decision-making, to develop trust among bedside nurses and to look
to errors as an opening for learning and an opportunity to improve
practice (Merrill, 2015; O’Connor & Carlson, 2016). Leaders and
nurses need to take responsibility to seek leadership education and
participation for their own professional growth and to develop their
own confidence and competence in leadership. Further, followers of
leaders should reflect on their influence on the support of their
leader. Encouragement and support, rather than criticism and pas-
sive-aggressive commentary, can diminish a leader’s effectiveness.
Hospital-acquired harm decreases as ward safety culture increases,
with leadership behaviour having a direct influence on patient out-
comes (O’Connor & Carlson, 2016).
3 | CONCLUSION
Patient safety is the responsibility of all healthcare workers, from
the highest executive to the bedside nurse; thus, effective leader-
ship is the nexus to engagement of staff to provide high-quality
care. Creating a just, blame-free workplace safety culture through
effective leadership and the recognition and fostering of up and
coming leader’s only serves to strengthen the team for the best pos-
sible patient outcomes. The positive well-being of our patients relies
on a culture of safety as the patient safety practices at the bedside
are heavily influential on patient outcomes. Whether directly or indi-
rectly, those with the most influence on a patient’s outcome is the
nurse at the bedside. With effective leadership, these bedside
nurses can be empowered to go above and beyond their self-
imposed boundaries to meet a vision shared by their leader without
fear of recrimination. A leader is looked upon for clear guidance
towards a common goal, this and more is provided by the effectual
leader.
Leadership styles that have claimed credence in today’s health-
care literature are those of transformational and transactional lead-
ers. These leaders can engage their staff to bring about the
necessary changes that make their nursing units stand out from the
crowd with increased levels of excellence in patient care. Unfortu-
nately, several barriers to the creation of a safety culture exist that
has resulted in poor patient care worldwide. The safety of our
patients relies on a culture of safety. A safe culture is one nurtured
by effective leadership and leadership styles used by organisational
and nurse leaders are the nexus to enhanced patient safety out-
comes.
4 | RELEVANCE TO PRACTICE
Leaders may not necessarily be in formal senior positions but may
be anyone who is influential in patient care. Patient safety is the
responsibility of all healthcare workers, from the highest executive
to the bedside nurse. Patient experiences are influenced not only by
the nurse at the bedside but the overall workings of the organisation
thus effective leadership throughout all levels, especially from clinical
nurses at the bedside, is essential in engaging staff to provide high
quality care for the best possible patient outcomes.
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CONTRIBUTIONS
Study design: MM, data collection and analysis: MM; and manuscript
preparation: MM, DS, VC.
ORCID
Melanie Murray http://orcid.org/0000-0002-6335-1356
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How to cite this article: Murray M, Sundin D, Cope V. The
nexus of nursing leadership and a culture of safer patient
care. J Clin Nurs. 2018;27:1287–1293. https://doi.org/
10.1111/jocn.13980
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