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OR I G I N A L A R T I C L E

Medical–surgical nurse leaders’ experiences with safety culture: An inductive qualitative descriptive study

Lisa Harton PhD, RN, FACHE, Chief Quality Officer |

Lisa Skemp PhD, FGSA, FAAN, Professor

Marcella Niehoff School of Nursing, Loyola

University Chicago, Chicago, Illinois, USA

Correspondence

Lisa Harton, 1016 BVM Hall, Marcella Neihoff

School of Nursing, Lake Shore Campus, 1032

W. Sheridan Road, Chicago, IL 60660, USA.

Email: [email protected]

Funding information

There are no sources of funding.

Abstract

Aim: The aim of this study is to describe safety culture as experienced by

medical–surgical nurse leaders.

Background: Safety culture remains a barrier in safer patient care. Nurse leaders play

an important role in creating and supporting a safety culture.

Methods: We used an inductive qualitative descriptive study using semistructured

interviews, document review and observations in a Midwestern community hospital

in the United States.

Results: Results of the study are as follows: making sure nurses are keeping patients

safe, making sure nurses have nursing interventions in place, expecting nurses to stop

unsafe acts or escalate when they feel uncomfortable, making sure nurses have what

they need to provide safe care, organization prioritizes patient safety and making

sure nurses are learning and growing emerged as themes describing safety culture.

Conclusions: Nurse leaders made sure patients were safe by making sure everyone

was doing their best to provide safe care. Insufficient time, too many priorities,

insufficient resources, poor physician behaviours and lack of respect for their role

emerged as barriers to leading a safety culture.

Implications for Nursing Management: Organizations must remove barriers for nurse

leaders to develop and lead a safety culture. Nurse leaders must learn to advocate

successfully for safe nursing care and professional work environments.

K E YWORD S

acute care, nurse manager, patient safety, safety culture

1 | BACKGROUND

The Institute of Medicine (IOM, 2000) seminal report on preventable

patient harm identified 44,000–98,000 deaths annually from

avoidable medical errors. Health care system leadership and

researchers responded to this problem by studying systems that led

to errors to create safer care processes while also addressing safety

culture (Gandhi et al., 2016). Despite efforts to improve patient safety,

one in 20 patients continue to experience preventable harm

(Panagioti et al., 2019). Delivering safe care requires leaders to estab-

lish, lead and sustain safety as a core value resulting in improved

safety culture (Gandhi et al., 2016). Safety culture is the product of

Received: 5 May 2022 Revised: 10 August 2022 Accepted: 29 August 2022

DOI: 10.1111/jonm.13775

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any

medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

© 2022 The Authors. Journal of Nursing Management published by John Wiley & Sons Ltd.

J Nurs Manag. 2022;30:2781–2790. wileyonlinelibrary.com/journal/jonm 2781

individual and group values, attitudes, perceptions, competencies, and

patterns of behavior that can determine the commitment to, and the

style and proficiency of an organization’s health and safety manage-

ment plan (Health and Safety Commission Advisory Committee on the

Safety of Nuclear Installations, 1993, p.339). A positive safety culture

in hospital nursing units resulted in fewer reported adverse patient

outcomes including decreased patient falls, medication errors,

pressure injuries, hospital associated infections and higher patient

satisfaction (Alanazi et al., 2022).

Leader expectations, support, prioritization and commitment to

patient safety, accountability, sharing data, daily management practices,

focusing on safety behaviours, teamwork and communication, learning

and improvement and executive rounding positively impact safety cul-

ture (Campione & Famolaro, 2018; Churruca et al., 2021; Frush

et al., 2018). A systematic review identified that organizational safety

cultures are underdeveloped or weak in regard to staffing, nonpunitive

response to errors, handovers and transitions of care and teamwork

across units (Reis et al., 2018). Failure of leadership to prioritize and

support patient safety has been associated with poor patient safety

outcomes (Patient Safety Advisory Group [PSAG], 2017).

Efforts to develop a safety culture have not had a significant

impact. For example, the Agency for Health care Research and Quality

(AHRQ) Hospital Survey on Patient Safety Culture (SOPS) 2021 trend-

ing report identified a 1% decrease in overall perception of patient

safety and 40% of hospitals reported a 5-point or more decrease in

management support for patient safety (Famolaro et al., 2021). Nurse

leaders (NLs) are a subset of administration and management respon-

dents that have the most favourable safety culture perceptions. They

lead Registered Nurses (RNs), a subset of nurse respondents within

the AHRQ SOPS survey, who, in contrast, have the least favourable

perception of safety culture.

Nurse leaders play an important role in creating and supporting a

safety culture and leading a professional nursing work environment. A

professional nursing work environment has been associated with bet-

ter safety culture and patient outcomes (Lee & Dahinten, 2020; Olds

et al., 2017). Adequate staffing, managerial support for nurses and

good nurse–physician relations contribute to a professional nurse

work environment (IOM, 2004). Hospital manager behaviours that

promote patient safety and transformational leadership styles influ-

ence and predict nurse-perceived patient safety (Anderson

et al., 2019; Campbell et al., 2021; Ferreira et al., 2022; Lee &

Dahinten, 2020; Weaver et al., 2017). Transformational leadership

had a significant indirect effect on adverse patient outcomes through

structural empowerment (Boamah et al., 2018). Structural empower-

ment explains how leaders can influence employees to accomplish

their work effectively by providing access to information, support,

resources and opportunities (Kanter, 1993).

Transformational leadership is a relational leadership style in

which followers have trust and respect for the leader and are moti-

vated to do more than is formally expected of them to achieve organi-

zational goals (Bass, 1985). Transformational leadership consists of

four core dimensions. Idealized influence describes a leader who is an

exemplary role model, sets high standards of conduct and articulates

the vision of the organization. Inspirational motivation occurs when

leaders articulate a compelling vision. Intellectual stimulation occurs

when leaders solicit a variety of opinions perspectives in making deci-

sions and empower employees to constantly be learning, looking for

and acting upon opportunities (Bass, 1985). Finally, individualized con-

sideration occurs when leaders coach or mentor to the individual dif-

ferences in needs of employees to help them reach their full potential

(Avolio et al., 1999).

Assessing safety culture in health care has relied predominantly

on quantitative methods that measure varying dimensions of a safety

culture but lack an understanding of cultural assumptions and behav-

iours (Churruca et al., 2021). Through a better understanding of nurse

leader experiences within the situational context of a medical–surgical

unit, safety culture perceptions will be better understood, behaviours

described and facilitators and challenges identified to provide insight

into areas for prioritization or improvement. Therefore, this study

aimed to describe medical–surgical nurse leader experiences with

safety culture in a Midwestern United States hospital to inform fac-

tors that support leading a safety culture in nursing. This study is part

of a larger study describing the similarities and differences in safety

culture experiences between RNs and nurse leaders.

2 | METHODS

2.1 | Design and participants

An inductive qualitative descriptive study was used for data collection

and analysis. A purposive sample of nurse leaders with at least

6 months experience supporting the medical–surgical units were

recruited through flyers, a recruitment email and during hospital

safety huddles. Safety huddles or short, stand-up meetings occurred

each morning between nurse leaders and their staff allowing teams to

actively manage quality and safety by looking back at performance

and looking ahead to proactively discuss safety concerns

(AHRQ, 2017). Data saturation was reached at 10 nurse leader partici-

pants. Nurse leaders were at a minimum bachelor’s prepared RNs that

had 24 h accountability for a direct care unit or units.

2.2 | Data collection

Informed consent was obtained. Data were collected through a semi-

structured interview guide. Interviews were conducted by the first

author, a nurse researcher with over 15 years of leadership experi-

ence in acute care settings. Interviews were conducted in secure and

comfortable locations chosen by the participants and lasted, on aver-

age, 1 h. Confidentiality was maintained by using pseudonyms during

transcription. Audio tapes of interviews were transcribed verbatim,

reviewed line-by-line and compared with the audio recordings to

ensure accuracy. The second author, a nurse researcher with expertise

in qualitative research, reviewed a sample of audio recordings and all

transcripts to validate transcriptions. Key policies, protocols and

2782 HARTON AND SKEMP

documents discussed in interviews were collected and reviewed to

enhance the credibility of data collection. Observations of 16 safety

huddles allowed the researcher to observe group safety behaviours

and were captured in field notes.

2.3 | Data analysis

Data analysis was conducted by two qualitative nurse researchers.

Inductive qualitative content analysis was applied to analyse and sum-

marize data resulting in six themes (Sandelowski, 2000). Analysis was

manual and occurred concurrently with data collection using a five-

step process (Miles et al., 2014). First, data were managed and orga-

nized into secure files. Second, data were read and re-read while

memoing emergent ideas to capture phrases and words to identify ini-

tial codes. Third, in vivo coding allowed clustering of similar data using

first cycle coding that was continuously revised to accommodate new

data. Then, pattern codes were generated through second cycle cod-

ing to identify emerging themes. Subthemes provided rich description

of participant experiences by providing quotes, emotions and context

to ensure that the voices, feelings, meanings and actions of the partic-

ipants were described in sufficient detail. In the fourth step, interpre-

tations were developed and assessed. Fifth, results were validated by

member checking and by researcher triangulation through consensus.

Findings were compared with what is known in the literature.

2.4 | Rigour

Rigour was established by adhering to the four criteria described by

Lincoln and Guba (1985). Credibility was ensured by pilot testing the

interview guide, flexible, systematic, purposive sampling, ensuring par-

ticipants had the freedom to provide rich information, participant-

driven data until saturation was reached, triangulation of data collec-

tion through multiple sources, accurate and timely transcription, data-

driven coding with member checking, investigatory triangulation and

on-going attention to context. Confirmability was ensured through

bracketing personal bias, investigator triangulation and member

checking. Dependability was ensured through a documented exten-

sive, detailed audit trail. Transferability or fittingness of the results is

determined by the reader.

2.5 | Ethical considerations

The study was approved by the University IRB and the study site

research ethics review committee.

3 | RESULTS

The 10 participants were female and held at minimum a bachelor’s

degree in nursing as was required for the role. There was variation in

age (28–62 years of age) and years of experience as a nurse leader

(2–21 years). All nurse leaders worked at least 40 h a week predomi-

nantly on the day shift (90%) (Table 1).

Six themes described nurse leader experiences with safety cul-

ture. Within the themes, 16 subthemes provided rich description of

the meaning of those experiences (Figure 1). This resulted in nurse

leaders making sure patients were safe by making sure everyone was

doing their best to provide safe care.

3.1 | Making sure nurses are keeping patients safe

Nurse leaders set expectations and held RNs accountable for gather-

ing information from and about their patients and ensuring a

T AB L E 1 Demographics

Characteristic

NL (n = 10)

% n

Gender

Male 0 0

Female 100 10

Role

Supervisor 40 4

Manager 50 5

Director 10 1

Age

20–29 10 1

30–39 50 5

40–49 30 3

50–59 10 1

Highest education level completed

Bachelor’s 90 9

Master’s 10 1

RN, number of years

4–5 10 1

6–10 20 2

> 10 70 7

Years as a nurse leader

2–3 20 2

4–5 10 1

6–10 40 4

>10 30 3

Hours worked per week

0–24 30 3

25–40 70 7

Shift most often worked

Days 90 9

Nights 0 0

Rotating 10 1

HARTON AND SKEMP 2783

collaborative plan to proactively keep patients safe. The subthemes

described knowing the patient by reviewing the electronic medical

record, bedside shift report to know the patient and catch things

upstream and risk assessments, when completed, determined patient

risks. This was described as the safest day.

When the patient is admitted there is collaborative,

effective communication with all care team members.

There’s a plan of care to keep the patient safe whether

it’s preventing falls, preventing any kind of harm. To

make sure that we have the best standards in place to

prevent harm from that patient. (RNL04)

Nurse leaders described RNs as spending a lot of time looking for

information that was not always accurate and did not transfer from

most settings outside of the hospital. Bedside shift report facilitated

knowing the patient and involving them in the plan of care which

helped RNs catch things upstream by validating the patient’s condi-

tion and ensuring safety interventions were in place. Although they

shared stories to help RNs understand the benefits of bedside shift

report and conducted audits to increase compliance, they were not

done consistently or accurately.

Handover is mind-boggling to me that people have

trouble getting nurses to buy into it because [I] can

give examples that demonstrate from a patient per-

spective what that means. I talk to my nurses about

the position they can put you in if you do not do it

right. You did not do handover and the IV rate is

wrong, you have an infiltrated IV. All these things that

the previous nurse maybe was part of and now you

cannot even ask those questions. Now you have got to

explain the situation to the patient and doctor, and you

do not have the background. (RNL02)

Finally, nurse leaders described risk assessments, when com-

pleted, determined patient risks to inform a clear plan to keep patients

safe. A review of a risk assessments confirmed that prevention inter-

ventions were recommended based on a calculated risk score. How-

ever, NLs described that RNs not having time and being too busy

were barriers to completing risk assessments.

3.2 | Making sure nurses have nursing interventions in place

Nurse leaders set expectations and held RNs accountable for having

nursing interventions in place. Nursing interventions were defined as

policies and protocols developed using professional standards and

evidence-based practice for RNs to follow to guide safe patient care.

The subthemes described setting expectations and holding staff

nurses accountable for following nursing interventions: checklists,

alarms, warnings and safety double checks and workarounds to keep

patients safe.

F I GU R E 1 Results

2784 HARTON AND SKEMP

The IV policy is a reference that my nursing team

utilizes. Recently there was another unit that wanted

to transfer a patient who was on a nitro drip for

high blood pressures that needed to be titrated.

Currently our team is not competent in that, nor

are we staffed to take care of that acuity to make sure

that we are monitoring that patient safely. So, they

were able to use that policy and stop it right there and

figure out a different plan to keep that patient safe.

(RNL02)

Nurse leaders could not agree on how prescriptive nursing inter-

ventions should be to support the use of nursing judgement. They

acknowledged that RNs did not always follow nursing interventions

placing patient safety at risk. Nursing interventions were not followed

because they were too complicated, confusing, unrealistic, ever-

changing, not easily accessible at the point of care, outdated and were

too open to interpretation. ‘You’re trying to coach on fall prevention

to the 17-page policy. By the time you get around to every nurse to

personally coach them, they’ve changed it’ (RNL04). Key policies were

reviewed to confirm this result. During a safety huddle observation, a

NL took over 15 min to explain a 17-page safety policy that RNs still

found confusing and unreasonable. The organization had shared gov-

ernance councils and improvement teams to incorporate RN input

into nursing interventions; however, nurse leaders described a lack of

RN engagement to participate. They also described not enough RN

representation, members not trained on how to use evidence-based

practice to develop nursing interventions and no training on managing

group conflict as barriers.

Nurse leaders made sure RNs understood expectations through

consistent, clear communication, auditing, rounding and feedback to

ensure learning and compliance. They acknowledged inconsistency in

how they set expectations and held RNs accountable.

We have hounded on medication safety so much or

even bigger is shift handover at the bedside. Finally,

we all agreed between the hospital leadership we are

really going to hold people accountable. You cannot

turn your head. We’ve got to hold people accountable

[slamming fist in hand]. (RNL06)

After tracking and coaching for so long, nurse leaders believed

RNs did not follow standards because they lost sight of the patient in

all the busyness and being overwhelmed.

Alarms, warnings, checklists and safety checks were supportive

when they were working, easily accessible and responded to. Nurse

leaders described that RNs did not always respond to alarms because

they were too busy or perceived socialization took priority over

answering alarms.

A lot of socialization takes priority over patient care. I

do not know if it’s because half the time they are so

busy and rundown that when they are not it’s ‘I have

to breathe. I do not want to do any work, I just want to

be able to chitchat and have some downtime’ or if it’s just a culture that we have grown. (RNL09)

They described that RNs did workarounds in nursing interven-

tions because of real- or perceived-time pressure, knowledge gaps

and lack of accountability.

3.3 | Expecting nurses to stop unsafe practices or escalate when they feel uncomfortable

Nurse leaders expected RNs to stop unsafe practices immediately,

reach out to others with more expertise when they were in unfamiliar

situations, and escalate, or reach up to the nurse leader or the rapid

response team, to meet immediate patient needs. The subthemes

described expecting direct conversations about safety, getting the

right eyes on the patient and we do not have great relationships with

our physicians.

No fear. I [RN] would not think twice about stopping

somebody from doing something if I felt it wasn’t the

right thing. I hear people talk about it, somebody will

tell me I saw so-and-so do this and I’ll say how did they

react when you let them know. Of course, the answer I

get is ‘I did not’. Not having that fear would be a safety

culture. They have the power to do it, I do not think

they always believe they have the power. (RNL01)

Direct conversations about safety occurred when a RN would

speak up immediately to anyone at any time to keep the patient safe

by stopping unsafe practices, poor practices or disrespectful behav-

iour. Nurse leaders described RNs as struggling to have direct conver-

sations and stopping unsafe practices that have resulted in patient

harm.

Sometimes they do not [speak up]. A lot of times that

is due to hierarchy, poor relationships that they have,

and some of it is based out of fear because they do not

want the provider mad or to get yelled at. There’s

opportunities in pockets and opportunities for collabo-

ration across the organization. (RNL10)

Nurse leaders coached, trained and encouraged direct conversa-

tions and stopping unsafe practices by recognizing and rewarding

these behaviours. They also sought to empower RNs by promoting

patient advocacy, reminding the RN of their duty and engaging the

CEO in advocating for the important role of the RN in the organiza-

tion. Nurse leaders had an open-door policy and followed up on RN

concerns to model how to have direct conversations. Fear, lack of

leader availability and lack of RN confidence were identified barriers.

Fear was attributed to not wanting to look incompetent or challenging

to physicians.

HARTON AND SKEMP 2785

Nurse leaders believed RNs used their resources to keep patients

safe in situations where they lacked experience or were unable to get

what they needed to keep the patient safe. Resources included lean-

ing on each other, other specialties, escalating to a nurse leader or

calling a rapid response team that brought additional resources such

as respiratory therapy and an intensive care unit nurse to the bedside

to assist. The charge nurse was the most valuable resource when they

were not busy and were approachable.

Nurse leaders described that resources were not available,

barriers not removed and negative experiences when escalating

a situation caused RNs to delay or question escalating, thereby placing

patients at risk. In particular, a pattern of poor behaviours from

physicians and other disciplines that was never addressed.

If it’s a one-time thing, you are having a bad night our

nurses do not care. Everyone has a bad day. It’s when

it’s a consistent repetitive [physician] behaviour that

we have tried to address. It’s just a slap in the face

from the provider and honestly the organization

because you are told we should not have to deal with

this and to have it consistently ignored on all levels is

just like a slap in the face. (RNL09)

Nurse leaders explained that RNs on their unit work well together

as a team, however, described challenges working with other depart-

ments. Aligned goals, positive attitudes, being approachable and reli-

able, good communication and leading by example facilitated working

together. They explained that developing relationships with other

departments, disciplines and each other while learning to appreciate

each other’s unique roles facilitated a safety culture.

The medical director is very engaged in providing edu-

cation and answering questions, teaching on new pro-

cedures. That’s good collaboration. That not only helps

with patient safety because they are an integrated part

of the care team but, they are helping develop nursing

along the way. (RNL10)

They believed there were some RNs that just did not care, were

too busy and burned out, prioritized socialization over helping and

chose to not speak up as barriers to working together.

Nurse leaders identified that poor relationships with physicians

contributed significantly to unsafe care.

The most pressing thing to be addressed is a way to

develop and foster relationships between these two

[RNs and physicians]. If we do not have a foundational

relationship, then we cannot respectfully work side-by-

side and learn from each other. (RNL01)

Unsafe delays in care were related to a lack of or unprofessional

response from physicians when RNs advocated for their patients’

health and safety needs. A nurse leader described ‘If the nurse feels

belittled, they aren’t going to bring something up that someone is

going to put down because they don’t feel comfortable based on

responses they received in the past’ (RNL03). As such, nurse leaders

focused on the RNs and worked with them to cultivate relationships

and professional, respectful communication between physicians and

RNs by role modelling. On the other hand, reported poor physician

behaviours were not addressed.

3.4 | Making sure nurses have what they need to provide safe care

Nurse leaders secured appropriate resources to keep RNs at the bed-

side. The subthemes described that balancing financially responsible

staffing with patient needs is challenging, and supplies and working

equipment are not always available to keep RNs at the bedside. Inade-

quate staffing contributed to the most unsafe day.

If we do not have staff and there’s patients that need

help you are in a bind. The organization is here to serve

the community, but if there is not nurses to take care

of them, what do we do? It’s been just take more

patients and that makes a nurse feel like it’s unsafe.

Where do you stop? (RNL07)

Although nurse leaders described appropriate nurse–patient

ratios, they acknowledged skill mix, inability to transfer high acuity

patients to a higher level of care, geographic patient placement on the

unit, patient and family dynamics, frequent discharges and admits and

patients that required multiple RNs to assist in their care as barriers.

When we are short staffed, I’m seeing patients not

ambulating in the hallway, call lights going off which

put our patients at risk of falling. Yesterday there was

a dressing change that was supposed to take place in

the morning, but it did not happen until the afternoon

so risk for infection. The interventions need to be com-

pleted but they aren’t because they just cannot get to

them. (RNL03)

Low RN turnover, decreased vacancies, RNs helping each other,

having and enforcing unit admission guidelines, dispersing acuity

among assignments and support such as a transport team so the

RN could focus on nursing care all facilitated safe care. They

addressed staffing shortages by being available to help, forcing RNs

to stay over their shift, calling in extra help, agency or travel RNs,

showing appreciation for RNs that pick up extra shifts and using

technology to supplement patient monitoring and responding to

patient needs.

Nurse leaders acknowledged that supplies and working

equipment were not always available to keep RNs at the bedside

due to a lack of support from departments they depended on for

delivery and repair. Nurse leaders felt disrespected as they were

2786 HARTON AND SKEMP

unable to use their authority or influence to get resources to keep

RNs at the bedside.

I do not feel that I am respected. I was trying to work

with our inventory supply to make sure that we had

the right supplies at the right time for our nurses so we

are not running around. He kept on going to the direc-

tors to get approval for things I wanted to try on my

unit. So, it was very frustrating. (RNL02)

3.5 | Organization prioritizes patient safety

The organization prioritized patient safety by communicating to all

departments and members of the health care team that patient safety

was the overarching priority. The subthemes described establishing

goals and providing transparency and communicating, listening to

understand and responding to nurse concerns.

It’s everyone having the same understanding of what a

culture of safety is. What does it look like, feel like and

then having shared outcome goals to help pull that

care team together more so that everyone’s on the

same page on providing that kind of care for that

patient. When everybody is on the same page about

safety it looks beautiful. (RNL02)

The CEO communicated and supported a vision of zero prevent-

able harm. Then, patient safety goals were developed and aligned across

all roles within the organization with routine transparency of outcomes.

Being able to focus on the quality of care and having

them be our metrics for the year has helped so the

nurses know we are not just focusing on financials we

are focusing on your patient and how we can prevent

any harm. (RNL03)

Facilitators included an online incident reporting system, safety

huddles and frequently reviewed visible patient safety dashboards.

There was variation between departments of what safety as a priority

for everyone meant, which left nurse leaders feeling disrespected and

unable to remove barriers for RNs.

My team members probably can speak to how I lead

and how I speak about it and share what their thoughts

are, but I believe from the actions from other depart-

ments that people do not share the same passion like

we do. It’s very frustrating and very sad because it’s

like banging your head on a wall. (RNL02)

Too many priorities and frequently changing priorities due

to frequent turnover in executive leadership were barriers leaving

nurse leaders feeling as if they were not doing anything good at all.

There’s so many quality indicators that we are trying to

focus on and there’s no support for any of that so it

relies on me. You cannot focus on all of them

every day and you feel like you aren’t doing anything

good at all. (RNL04)

Sometimes I feel like we are firefighting. We’re not

preventing before it happens which then does not

make it feel like a safety culture. You have to prioritize

and it’s very hard to understand where my focus needs

to be. I know patient safety is the number one focus

but with everything else coming at me what can I set

aside to really be able to do what I need to do.

(RNL03)

They prided themselves in communicating, listening to under-

stand and responding to RN concerns. They described:

It’s always being open to listen and saying I appreciate

you talking this through and just please be honest with

me. I think some of that is just being open and having

my door open and always letting people know that I’m

here if you need anything. (RNL05)

Nurse leaders communicated through staff meetings, weekly

updates, emails, daily rounds and daily huddles. They identified the

barriers of inconsistent messaging among nurse leaders, a lack of

sharing among nurse leaders to spread learnings and a lack of time

for nurse leaders to spend time listening, communicating, and

responding with RNs. Although they described themselves as

advocates for RNs, they identified a disconnection between system

expectations and what was happening at the bedside with an

inability to effectively lead or advocate on behalf of RNs. They

described how ‘I think that there’s sometimes a disconnect

between what we’d like to do as a system and where we are right

at the bedside … The communication chains are not always

consistent and robust, and we don’t share very well’ (RNL06).

Furthermore,

If we could just get consistent leadership…it feels like

we are always starting over and having to build new

relationships. There’s a lot of fear because of the lack

of relationships and trust because no one really trusts

anybody anymore because they do not know the

people. You have to run things by them, notify them,

versus just moving things faster because I do not want

to get in trouble. (RNL04)

3.6 | Making sure nurses are learning and growing

There was a structure and process to learn from internal threats to

patient safety and through formal programs to develop RN skills. The

HARTON AND SKEMP 2787

subthemes described a nonpunitive response and follow through,

supporting nurse knowledge and education and learning from audits

and stories.

If something happens, we do not point fingers and dis-

cipline you, we put in an incident report, gather data

and then we build off of that, because it only makes

everybody stronger instead of just pointing fingers.

(RNL07)

Building trusting relationships with RNs and respectful coaching

facilitated reporting of safety events.

Relationship with your team is so important because

they need to find comfort in their leader. I have said so

many times how to get ahold of me when I’m not here.

Daily connections provide comfort to nurses. They

need as much information that pertains to them as

possible because I think that reduces anxiety. (RNL04)

Providing real-time, nonjudgmental feedback helped RNs learn.

At safety huddles, nurse leaders were observed following up by bring-

ing issues back for learning. Meeting with individuals and other

departments, sharing learnings through newsletters, debriefing in real

time and supporting root cause analysis to identify and change system

issues were facilitators.

Then RNs learned through an online learning system and through

financial support for certification and conferences; however, nurse

leaders acknowledged that RNs did not participate because on-going

education was not required. They were concerned with RNs’ ability to

provide safe care because of the orientation process. Nurse leaders

identified both role conflict and overload. For example, they did not

feel qualified to develop their own orientation process and struggled

finding competent preceptors to train new RNs. They also struggled

with the lack of leader training or development for themselves. ‘There is lack of orientation for leaders. You’re trying to develop yourself,

develop your team, maintain day-to-day practice, and then still make

sure your team feels like you’re available and there to support them’ (RNL04). They also shared stories about clinical situations to create a

learning environment. Finally, they audited key processes and shared

the results and impact of not following key processes as a mechanism

for learning.

4 | DISCUSSION

The role of the nurse leader is to provide the vital link between the

organization’s strategy and the frontline nurses (American Organiza-

tion of Nurse Executive [AONE], 2015). Nurse leaders described that

experiences with safety culture provided context to understand what

is influencing safety culture perceptions. The organization aligned the

vision to support patient safety; however, support for nurse leaders to

deliver on this was lacking.

Nurse leaders described significant barriers in developing a safety

culture including a lack of time, role overload, organizational con-

straints, inability to effectively lead, lack of power, role conflict and

lack of respect for their role. Lack of time prevented nurse leaders

from spending the time they wanted to build relationships with RNs.

This left them feeling frustrated, disrespected and as if they were not

doing anything good at all. Chronic fatigue associated with 24 h

accountability and intense role expectations has been associated with

nurse leader intent to leave the role (Steege et al., 2017). To address

nurse leaders being too busy, recommendations include shifting from

busy work to focused, strategic work through an energy preservation

framework to promote vitality that drives engagement, productivity

and innovation (Shirey & Hites, 2015). However, empirical support of

nurse leader tactics to promote prioritization and accomplishment of

duties is lacking. To retain nurse leaders and change the trajectory of

safety culture in nursing, attention needs to be paid to these experi-

ences which will require different organization understanding and

support of the nurse leader role.

Nurse leaders need to be able to incorporate all dimensions of

the transformational leadership framework to positively impact safety

culture (Avolio et al., 1999) while being able to lead a professional

work environment (IOM, 2004). Nurse leaders could not inspire and

motivate through transformational leadership because of lack of

power and inability to influence a professional work environment. This

rendered them ineffective and led to unintended consequences

including emotional stress and feelings of inadequacy. For example,

they described a clear, compelling patient safety vision and multiple

methods to communicate that vision and listen to RNs; however, they

were unable to effectively address issues that were raised. Although

they wanted to support RNs, they were unable to influence adequate

staffing, could not obtain resources to keep RNs at the bedside and

lacked power or organizational support to address poor physician

behaviours. They also provided information and some levels of sup-

port but the inability to provide resources prohibited RNs from engag-

ing in decision making and professional development, all components

of structural empowerment (Kanter, 1993). Nurse leaders must

become skilled at advocating for a professional work environment.

The lack of power to create and sustain a healthy work environment

must be further studied. One cannot empower others and expect

them to perform beyond minimal requirements if basic resources are

not available and if nurse leaders are not empowered themselves. The

role of structural empowerment and a professional work environment

in developing a safety culture should be further explored. Organiza-

tions must also take a stand and not tolerate poor behaviours from

any members of the health care team.

The desire to support RNs to provide safe care within a positive

safety culture without the power or ability to do so left nurse leaders

feeling frustrated, disrespected, emotionally distressed and inade-

quate. These results suggest that nurse leaders’ safety culture experi-

ences are conflicting with or may be diluted by combining their results

with nonnursing administrative and management participant results of

the AHRQ SOPS. Isolating nurse leader results in addition to research

focused on understanding the nurse leader role in creating a safety

2788 HARTON AND SKEMP

culture to redesign or support differently the role is necessary to

change the trajectory of safety culture in nursing.

5 | LIMITATIONS

A pandemic was experienced after three interviews; however, the

hospital did not experience a surge of patients until the final validation

of results. The researcher served in a leadership role at the organiza-

tion without any formal or matrixed authority over the participants.

While this research was conducted in one hospital in the Midwestern

United States, research on how leadership and safety culture in differ-

ent contexts nationally and internationally is needed to further enrich

our understandings of safety culture in acute care. Although these

results are not intended to be generalizable, the rich description will

support the reader in determining the transferability of the results

within their own practice.

6 | CONCLUSION

This study provided important insights into nurse leader experiences

with safety culture and safe patient care within medical–surgical units

in an acute care hospital. Nurse leaders described many barriers in

developing and leading a safety culture and providing safe care. If

nurse leaders are accountable for safe nursing care, they need to be

able to use their knowledge, influence, power and authority to advo-

cate for safe nursing care and a healthier professional work environ-

ment. Organizations must support differently or consider a

fundamental redesign of the nurse leader role to support and

empower nurse leaders as they are the connection between system

strategy and safe execution at the bedside.

6.1 | Implications for Nursing Management

Safety culture is facilitated when organizational leadership is deeply

involved with and attentive to issues frontline workers face and have

an understanding of the established norms and hidden cultures that

guide behaviours (AHRQ, 2019). Although nurse leaders described

many processes for understanding issues RNs experienced in provid-

ing safe patient care, they described not having the ability or influence

to advocate successfully on the behalf of RNs to resolve those issues.

Nurses readily embrace advocating for the patient; however, advocat-

ing on behalf of the profession, oneself or the work environment

although clearly outlined in nursing standards of practice and code of

ethics must also be prioritized. Nurse leaders need to gain advocacy

skills and engage in activities that promote the profession including

teaching, mentoring, peer review, involvement in professional associa-

tions and knowledge development and dissemination (American

Nurses Association, 2015).

Nurse leaders are influential in creating a professional environ-

ment and fostering a culture where interdisciplinary team members

are able to contribute to optimal patient outcomes and grow pro-

fessionally (AONE, 2015). However, these nurse leaders found

themselves overwhelmed with too many priorities and not having

enough time to effectively lead and achieve a safety culture. Nurse

leaders were busy with too many priorities that prevented them

from spending time developing RNs, facilitating relationships and

assuring adequate resources for making sure patients were safe.

Nurse leaders must incorporate all elements of transformation

leadership into their practice while focusing on and prioritizing the

elements of structural empowerment and creating a healthy

professional work environment (American Association of Critical

Care Nurses (AACN), 2016: Shirey & Hites, 2015). To do this,

system level change is critical, change that clearly situates nurse

leaders as transformational leaders who have the power and

administrative support to lead. Furthermore, given the discrepancy

between nurse leaders and RN perceptions of safety culture (AHRQ

SOPS citation), research on RNs perceptions of safety culture is

needed to more fully understand the acute care safety culture

context to then improve nursing effectiveness and promote safe

patient care.

CONFLICT OF INTEREST

The authors disclose no conflict of interest.

ETHICS STATEMENT

This study was approved by the Loyola University, Chicago Research

Ethics Committee (approval number 212782). Informed consent was

obtained from all participants in the study.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from IRB

restricted access. Restrictions apply to the availability of these data,

which were used under licence for this study. Data are available from

the author(s) with the permission of IRB restricted access.

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How to cite this article: Harton, L., & Skemp, L. (2022).

Medical–surgical nurse leaders’ experiences with safety

culture: An inductive qualitative descriptive study. Journal of

Nursing Management, 30(7), 2781–2790. https://doi.org/10.

1111/jonm.13775

2790 HARTON AND SKEMP

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