1. Kiper, Valerie DNP, MSN, RN, NE-BC


Abstract: Because nurses have the most interaction with patients, nurse leaders at all levels can influence organizational safety culture.


Article Content

The modern concept of patient safety was addressed by Florence Nightingale over 150 years ago in her Notes on Nursing. Nightingale identified two key aspects that continue to resonate. The first aspect is that it isn't the issue of being physically away from the bedside that's problematic; rather, it's the failure to ensure that there's a plan to provide safe patient care in those situations and empower others to think for themselves.

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The second aspect focuses on leadership. Nightingale cited the issue of those in charge not appreciating the roles and responsibilities of being in charge. She believed a leader's source of pride should be in establishing safety systems that don't depend solely on one person. Nightingale wrote of "petty management," recognizing that leaders can't be present at all times and it isn't healthy for them to think they can be. She stressed the importance of proactive critical thinking by encouraging nurses to determine how to prevent adverse events from occurring should the nurse need to be away from the bedside.


By improving team communication and systems design, we can create a culture of safety that empowers our colleagues to feel comfortable speaking up, even if it means we're challenging organizational authority. To do so requires transformational nurse leaders, both formal and informal.


Improving communication

There exists a mistaken impression that any error in healthcare is the result of malfeasance; this belief promotes a culture of blame and punishment, with an accompanying hesitancy of employees to report concerns. However, poor team communication is responsible for 70% to 80% of medical errors. A strong safety climate is linked to nurses' adherence to safe work practices, and effective teamwork promotes a culture of safety through the positive outcomes gained by working together. That's why interprofessional teamwork is a key to patient safety and overall patient care.


So, how do we improve team communication to prevent errors? Anticipating team members' needs, being familiar with procedures, and having the right skill mix are factors that have been identified as being important for effective teamwork. Team members must know their roles within the team and be alert to the emotional exhaustion of their colleagues. If we don't identify when a team member is struggling with personal issues, emotional exhaustion, or incivility, it may lead to a decline in patient safety.


We've heard for many years that "nurses eat their young." Workplace incivility, such as bullying and lateral violence, occurs in all settings and comes in many forms, both subtle and blatant. The American Nurses Association (ANA) defines bullying as "repeated, unwanted harmful actions intended to humiliate, offend, and cause distress in the recipient." According to the ANA, bullying threatens nurse and patient safety, and the nursing profession as a whole. First and foremost, incivility needs to be reported to those in charge. Strategies must be put in place to recognize and address incivility, and we must establish a zero-tolerance approach within our organizations.


One study found that indicators of nurse job satisfaction include friendships made at work, control in personal practice, and nurse-physician collaboration. It makes sense that promoting nurse satisfaction helps decrease incivility and improve patient safety. If nurses have increased collaboration and open communication with healthcare providers, they'll feel more comfortable reporting patient information that may potentially prevent infections, falls, or a decline in the progress needed for discharge, which translates to improved patient safety.


It's also been noted that effective communication between nurses and their supervisors and peers boosts job satisfaction, as well as increasing patient safety. Patients depend on nurses to communicate their needs to all members of the healthcare team. As clinical nurses, charge nurses, and other nurse leaders discuss patient issues, evidence-based practices, and organizational processes, we're making the work environment safer for ourselves and our patients.


Success in the workplace is often contingent on a leader's ability to effect positive change and inspire others to higher levels of achievement. Poor nurse job satisfaction can be minimized by engaging staff members in developing a common mission and vision, along with practice goals, in any setting. Experienced nurse leaders can also help prevent negative experiences for new nurse leaders by spending time teaching and coaching them, guiding them in seeking differing perspectives when faced with problems to solve, and helping them find new ways to improve the work environment.


Improving systems

In today's rapidly changing healthcare environment, we also have to focus on systems design. It's imperative that we establish effective, sustainable reporting systems that support transparency and freedom from punitive actions. An organization won't be able to change a punitive culture if it doesn't empower its employees. A shift in culture requires leaders who promote teamwork, transformative values, and innovative practices to improve care quality and patient safety.


Leadership styles explain how leaders engage with others. The most prominent leadership styles in healthcare literature are transformational and transactional leadership (see Transformational vs. transactional leadership styles). Both styles use different forms of motivation to engage staff. Let's take a closer look.


Transformational leadership is associated with positive patient outcomes as a result of developing trust, which leads to a blameless safety culture. This "just culture" is a nonpunitive environment in which reckless behavior isn't tolerated, but inadvertent adverse events are used as a stepping stone to improve practice. Additionally, transformational leaders value their team members' opinions, respect their experience, affirm their ideas, and involve them in decision making.

Figure. Transformati... - Click to enlarge in new windowFigure. Transformational vs. transactional leadership styles

Leadership engagement at the unit level has significant positive effects on the reporting of errors and adverse events because leaders who engage their staff members encourage an environment of open communication. Creating a just culture through transformational leadership, while recognizing and fostering up-and-coming leaders, strengthens the team. Leaders may not necessarily be in formal positions, but may be anyone who's influential in patient care. Think about the role you play in promoting a safety culture within your own work unit. Patient safety is the responsibility of all healthcare workers, from boardroom to bedside. Effective leadership at all levels-especially from clinical nurses at the bedside-is essential to provide high-quality care for the best possible patient outcomes.


Transactional leadership may be helpful when faced with a crisis situation in which an authoritative and direct approach is needed. Many nurses still cling to this type of leadership style, which can be detrimental to long-term organizational dynamics. Unfortunately, new nurses are often promoted quickly without much experience with or mentoring on leadership styles. In an attempt to be successful, and out of fear of failing, they may become authoritative to accomplish their goals.


Continued hierarchical and autocratic control has been proven to be ineffective in improving quality patient outcomes and motivating employees. However, it's important to note that even the most effective transformational leader may fail without possessing key day-to-day transactional management skills.


Essential learning

For clinical nurses, a considerable level of technical skill and clinical expertise is necessary because the nurse is typically involved in direct supervision of patient care and may be required to help train and mentor novice nurses. As nurses advance from lower to higher levels in an organization, more conceptual skills are needed, including making a commitment to support the mission, vision, and goals of the organization; accepting the constant changes within a complex healthcare system while facing reimbursement and cost reduction challenges; and understanding the needs of external customers.


Nurses benefit from seeking leadership education for their own professional growth and to develop confidence and competence in leadership skills. It's beneficial to conduct a leadership style assessment to provide a baseline determination of the predominant leadership style across your particular service line. Mentoring, role-playing, developmental workshops, and performance evaluation play a critical role in leadership education.


Balancing act

Creating safe care environments requires nurse leaders to "listen and learn," and involve employees in decision making. Nurse leaders must forge cooperative relationships, while anticipating and embracing change, to improve patient safety and care quality. As a former nurse executive, I often summarize the concepts of just culture and patient safety in the following way: Leaders need to support and build trusting relationships, implement best practices by employing objective outcome analysis and facilitating proactive problem solving, and encourage an atmosphere of interdisciplinary teamwork and professional growth. This requires learning the delicate balance between creativity and stability. It's crucial in our current healthcare environment to have leaders who can balance patient safety, performance improvement, and quality with effective and efficient care delivery systems.


cheat sheet

Pros and cons

Transformational leadership

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Pros: The leader applies creative approaches to problem solving, acts as a mentor and teacher, considers the individual and his or her needs, is able to motivate others, is able to meet organizational goals, and creates a collective sense of mission.


Cons: The leader may not be tolerant of opposing views and may tend to use coercive power to influence others to enhance his or her own goals.


Best used: The transformational leadership style is best used in service line development, shared governance models, and organizations seeking Magnet(R) recognition or Pathway to Excellence(R) designation.


Transactional leadership


Pros: The leader focuses on short-term goals and efficiency, favors structured policies and procedures, and is a rule follower.


Cons: The leader may not individualize others' needs or focus on their personal development, may tend to be inflexible and opposed to change, and may use management by exception and negative reinforcement.


Best used: The transactional leadership style is best used during crisis or disaster situations.




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