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: [email protected]

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

13652702, 2018, 5-6, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.13980 by Southern C

ross U niversity, W

iley O nline L

ibrary on [06/03/2023]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

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

1288 | MURRAY ET AL.

13652702, 2018, 5-6, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.13980 by Southern C

ross U niversity, W

iley O nline L

ibrary on [06/03/2023]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

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

MURRAY ET AL. | 1289

13652702, 2018, 5-6, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.13980 by Southern C

ross U niversity, W

iley O nline L

ibrary on [06/03/2023]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

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

1290 | MURRAY ET AL.

13652702, 2018, 5-6, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.13980 by Southern C

ross U niversity, W

iley O nline L

ibrary on [06/03/2023]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

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.

MURRAY ET AL. | 1291

13652702, 2018, 5-6, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.13980 by Southern C

ross U niversity, W

iley O nline L

ibrary on [06/03/2023]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

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

REFERENCES

Agnew, C., Flin, R., & Reid, J. (2012). Nurse leadership and patient safety.

BMJ, https://doi.org/10.1136/bmj.e4589

Aiken, L. H., Sloane, D. M., Clarke, S., Poghosyan, L., Cho, E., You, L., . . .

Aungsuroch, Y. (2011). Importance of work environments on hospital

outcomes in nine countries. International Journal for Quality in Health

Care, 23(11), 357–364.

Ammouri, A. A., Tailakh, A. K., Muliira, J. K., Geethakrishnan, R., & Al

Kindi, S. N. (2015). Patient safety culture among nurses. International

Nursing Review, 62(1), 102–110. https://doi.org/10.1111/inr.12159

American Nurses Credentialing Center. (2017). Announcing a New Model

for ANCC’s Magnet Recognition Program. Retrieved from: http://

www.nursecredentialing.org/MagnetModel

Auer, C., Schwendimann, R., Koch, R., De Geest, S., & Ausserhofer, D.

(2014). How hospital leaders contribute to patient safety through the

development of trust. The Journal of Nursing Administration, 44(1),

23–29. https://doi.org/10.1097/nna.0000000000000017

Bargagliotti, L. A. (2012). Work engagement in nursing: a concept analy-

sis. Journal of Advanced Nursing, 68(6), 1414–1428. https://doi.org/

10.1111/j.1365-2648.2011.05859.x

Bowie, P. (2010). Leadership and implementing a safety culture. Practice

Nurse, 40(10), 32–35. Retrieved from http://www.practicenurse.co.uk/

Brady Germain, P., & Cummings, G. G. (2010). The influence of nursing

leadership on nurse performance: A systematic literature review.

Journal of Nursing Management, 18(4), 425–439. https://doi.org/10.

1111/j.1365-2834.2010.01100.x

Brewer, C. S., Kovner, C. T., Djukic, M., Fatehi, F., Greene, W., Chacko, T.

P., & Yang, Y. (2016). Impact of transformational leadership on nurse

work outcomes. Journal of Advanced Nursing, 72(11), 2879–2893.

https://doi.org/10.1111/jan.13055

Burns, J. M. (1978). Leadership. New York, NY: Harper & Row.

Castel, E. S., Ginsburg, L. R., Zaheer, S., & Tamim, H. (2015). Understand-

ing nurses’ and physicians’ fear of repercussions for reporting errors:

Clinician characteristics, organization demographics, or leadership fac-

tors? BMC Health Services Research, 15(1), https://doi.org/10.1186/

s12913-015-0987-9

Cope, V. C., & Murray, M. (2017). Leadership styles in nursing. Nursing

Standard, 31(43), 61–70. https://doi.org/10.7748/ns.2017.e10836

Cowden, T.L., & Cummings, G.G. (2015) Testing a theoretical model of

clinical nurses’ intent to stay. Health Care Management Review. 40(2),

169–181. https://doi.org/10.1097/HMR.0000000000000008

Cummings, G. (2012). Editorial: Your leadership style—How are you

working to achieve a preferred future? Journal of Clinical Nursing, 21

(23–24), 3325–3327. https://doi.org/10.1111/j.1365-2702.2012.

04290.x

Cummings, G. G., MacGregor, T., Davey, M., Lee, H., Wong, C. A., Lo, E.,

. . . Stafford, E. (2010). Leadership styles and outcome patterns for

the nursing workforce and work environment: A systematic review.

International Journal of Nursing Studies, 47(3), 363–385. https://doi.

org/10.1016/j.ijnurstu.2009.08.006

Daly, J., Jackson, D., Mannix, J., Davidson, P., & Hutchinson, M. (2014).

The importance of clinical leadership in the hospital setting. Journal

of Healthcare Leadership, 75, https://doi.org/10.2147/jhl.s46161

Day, H. (2014). Engaging staff to deliver compassionate care and reduce

harm. British Journal of Nursing, 23(18), 974–980. https://doi.org/10.

12968/bjon.2014.23.18.974

Dignam, D., Duffield, C., Stasa, H., Gray, J., Jackson, D., & Daly, J. (2011).

Management and leadership in nursing: An Australian educational

perspective. Journal of Nursing Management, 20(1), 65–71. https://doi.

org/10.1111/j.1365-2834.2011.01340.x

Disch, J., Dreher, M., Davidson, P., Sinioris, M., & Wainio, J. A. (2011).

The role of the chief nurse officer in ensuring patient safety and

quality. The Journal of Nursing Administration, 41(4), 179–185.

https://doi.org/10.1097/nna.0b013e318211874b

Doody, O., & Doody, C. M. (2012). Transformational leadership in nursing

practice. British Journal of Nursing, 21(20), 1212–1218. https://doi.

org/10.12968/bjon.2012.21.20.1212

Enterkin, J., Robb, E., & McLaren, S. (2013). Clinical leadership for high-

quality care: Developing future ward leaders. Journal of Nursing Man-

agement, 21(2), 206–216. https://doi.org/10.1111/j.1365-2834.2012.

01408.x

Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation

Trust Public Inquiry. Retrieved from http://www.midstaffpublicin

quiry.com

Giltinane, C. L. (2013). Leadership styles and theories. Nursing Standard,

27(41), 35–39. https://doi.org/10.7748/ns2013.06.27.41.35.e7565

Grindel, C. G. (2016). Clinical leadership: A call to action. Medsurg Nurs-

ing, 25(1).

Haycock-Stuart, E., & Kean, S. (2012). Does nursing leadership affect the

quality of care in the community setting? Journal of Nursing Manage-

ment, 20(3), 372–381. https://doi.org/10.1111/j.1365-2834.2011.

01309.x

Hendricks, J., Cope, V., & Baum, G. (2015). Postgraduate nurses’ insights into the nursing leadership role. Do they intuitively link the role to

patient safety? Journal of Nursing Education and Practice, 5(9), 72–77.

https://doi.org/10.5430/jnep.v5n9p72

Jarrett, M. (2017). Patient safety and leadership: Do you walk the walk?

Journal of Healthcare Management, 62(2), https://doi.org/10.1097/

JHM-D-17-00005

Kaufman, G., & McCaughan, D. (2013). The effect of organisational cul-

ture on patient safety. Nursing Standard, 27(43), 50–56. https://doi.

org/10.7748/ns2013.06.27.43.50.e7280

Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human:

Building a safer health system. Washington, DC: National Academy

Press.

Kutney-Lee, A., Germack, H., Hatfield, L., Kelly, S., Maguire, P., Dierkes,

A., . . . Aiken, L.H. (2016). Nurse engagement in shared governance

and patient and nurse outcomes. The Journal of Nursing Administra-

tion, 46(11), 605–612. https://doi.org/10.1097/NNA.

0000000000000412

Ledlow, G., & Coppola, N. (2014). Leadership for health professionals:

Theory, skills and applications, 2nd ed.. Burlington, MA: Jones & Bar-

tlett Learning.

Lievens, I., & Vlerick, P. (2013). Transformational leadership and safety

performance among nurses: The mediating role of knowledge-related

job characteristics. Journal of Advanced Nursing, 70(3), 651–661.

https://doi.org/10.1111/jan.12229

McFadden, K. L., Stock, G. N., & Gowen, C. R. (2015). Leadership, safety

climate, and continuous quality improvement. Health Care Manage-

ment Review, 40(1), 24–34. https://doi.org/10.1097/hmr.

0000000000000006

Merrill, K. C. (2015). Leadership style and patient safety. The Journal of

Nursing Administration, 45(6), 319–324. https://doi.org/10.1097/nna.

0000000000000207

Moss, S., Mitchell, M., & Casey, V. (2017). Creating a culture of success:

Using the Magnet Recognition Program as a framework to engage

nurses in and Australian healthcare facility. Journal of Nursing Admin-

istration, 47(2), 116–122.

1292 | MURRAY ET AL.

13652702, 2018, 5-6, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.13980 by Southern C

ross U niversity, W

iley O nline L

ibrary on [06/03/2023]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

Muls, A., Dougherty, L., Doyle, N., Shaw, C., Soanes, L., & Stevens, A.

(2015). Influencing organisational culture: A leadership challenge. Bri-

tish Journal of Nursing, 24(12), 633–638. https://doi.org/10.12968/

bjon.2015.24.12.633

O’Connor, S., & Carlson, E. (2016). Safety culture and senior leadership

behavior. The Journal of Nursing Administration, 46(4), 215–220.

https://doi.org/10.1097/NNA.0000000000000330

Reid, K. B., & Dennison, P. (2011). The clinical nurse leader (CNL): Point-

of-care safety clinician. Online Journal of Issues in Nursing, 16(1).

Roche, M. A., Duffield, C., Dimitrelis, S., & Frew, B. (2015). Leadership

skills for nurse unit managers to decrease intention to leave. Nursing:

Research and Reviews, 5, 57–64.

Rotteau, L., Shojania, K. G., & Webster, F. (2014). ‘I think we should just

listen and get out’: A qualitative exploration of views and experiences

of Patient Safety Walkrounds: Table 1. BMJ Quality & Safety, 23(10),

823–829. https://doi.org/10.1136/bmjqs-2012-001706

Sammer, C. E., Lykens, K., Singh, K. P., Mains, D. A., & Lackan, N. A.

(2010). What is patient safety culture? A review of the literature.

Journal of Nursing Scholarship, 42(2), 156–165. https://doi.org/10.

1111/j.1547-5069.2009.01330.x

Sexton, J. B., Sharek, P. J., Thomas, E. J., Gould, J. B., Nisbet, C. C.,

Amspoker, A. B., . . . Profit, J. (2014). Exposure to leadership Walk-

Rounds in neonatal intensive care units is associated with a better

patient safety culture and less caregiver burnout. BMJ Quality and

Safety, 23(10), 814–822. https://doi.org/10.1136/bmjqs-2013-

002042

Sherman, R. (2012). What followers want in their nurse leaders. American

Nurse Today, 7(9).

Sherman, R., & Pross, E. (2010). Growing future nurse leaders to build

and sustain healthy work environments at the Unit Level. OJIN, 15

(1), https://doi.org/10.3912/OJIN.Vol15No01Man01

Sherman, R., Schwarzkopf, R., & Kiger, A. J. (2011). Charge nurse per-

spectives on frontline leadership in acute care environments.

International Scholarly Research Network, https://doi.org/10.5402/

2011/164052

Squires, M., Tourangeau, A., Spence Laschinger, H. K., & Doran, D.

(2010). The link between leadership and safety outcomes in hospitals.

Journal of Nursing Management, 18(8), 914–925. https://doi.org/10.

1111/j.1365-2834.2010.01181.x

Vaismoradi, M., Bondas, T., Salsali, M., Jasper, M., & Turunen, H. (2012).

Facilitating safe care: A qualitative study of Iranian nurse leaders.

Journal of Nursing Management, 22(1), 106–116. https://doi.org/10.

1111/j.1365-2834.2012.01439.x

Vogelsmeier, A., Scott-Cawiezell, J., Miller, B., & Griffith, S. (2010). Influ-

encing leadership perceptions of patient safety through just culture

training. Journal of Nursing Care Quality, 25(4), 288–294. https://doi.

org/10.1097/ncq.0b013e3181d8e0f2

Wong, C. A., & Giallonardo, L. M. (2013). Authentic leadership and

nurse-assessed adverse patient outcomes. Journal of Nursing Manage-

ment, 21(5), 740–752. https://doi.org/10.1111/jonm.12075

World Health Organisation. (2009, August). Hand hygiene: Why, how &

when? Retrieved from http://www.who.int/gpsc/5may/Hand_Hygie

ne_Why_How_and_When_Brochure.pdf?ua=1

Zaheer, S., Ginsburg, L., Chuang, Y., & Grace, S. L. (2015). Patient safety

climate (PSC) perceptions of frontline staff in acute care hospitals.

Health Care Management Review, 40(1), 13–23. https://doi.org/10.

1097/hmr.0000000000000005

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

MURRAY ET AL. | 1293

13652702, 2018, 5-6, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/jocn.13980 by Southern C

ross U niversity, W

iley O nline L

ibrary on [06/03/2023]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense