Nursing leadership style and error management culture: a scoping review

Abstract

Purpose

This paper aims to assess the influence of nursing leadership style on error management culture (EMC).

Design/methodology/approach

This scoping review was conducted following the integrative review methodology of the Joanna Briggs Institute (JBI) and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed, CINAHL, Scopus, Web of Science, Embase and EBSCO databases were systematically searched to identify studies on nursing leadership, error management and measurement, and error management culture. The studies’ methodological quality was then assessed using the JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies.

Findings

Thirteen manuscripts were included for review. The analysis confirmed that nursing leadership plays an important role in EMC and nurses’ intention to report errors. Three emerging themes were identified: 1) leadership and EMC; 2) leadership and the intention to report errors; and 3) leadership and error rate.

Research limitations/implications

A major limitation of the studies is that errors are often analyzed in a transversal way and associated with patient safety, and not as a single concept.

Practical implications

Healthcare managers should promote training dedicated to head nurses and their leadership style, for creating a good work environment in which nurses feel free and empowered to report errors, learn from them and prevent their reoccurrence in the future.

Originality/value

There is a positive relationship between nursing leadership and error management in terms of reduced errors and increased benefits. Positive nursing leadership leads to improvements in the caring quality.

Citation

Moraca, E., Zaghini, F., Fiorini, J. and Sili, A. (2024), "Nursing leadership style and error management culture: a scoping review", Leadership in Health Services, Vol. 37 No. 4, pp. 526-547. https://doi.org/10.1108/LHS-12-2023-0099

Introduction

Medical errors and patient safety remain major issues for many hospitals worldwide (Yusuf and Irwan, 2021). It has been estimated that every year, approximately 98,000 patient deaths and 1.5 million patient injuries are due to medical errors (Yusuf and Irwan, 2021), and between 200,000 and 440,000 hospital deaths worldwide are related to patient safety issues (Elkin et al., 2016; James, 2013). Medical errors refer to mistakes at any stage of the caring process (e.g. diagnosis, treatment, management or other aspects of healthcare delivery), leading to patient injury or death (Liukka et al., 2020).

Healthcare systems suffer a wide variety of quality problems, including the underuse, overuse and misuse of health services (Zaheer et al., 2021). They also face various challenges related to the complexity of healthcare, which exposes patients to increased risks of adverse events in clinical practice (Liukka et al., 2020). Errors are rarely the result of simple failures of healthcare professionals but are rather due to underlying causes (Nicklin et al., 2004). A prerequisite for enhancing clinical practices, as identified by the Institute of Medicine (IoM), is the development of safety culture (Farag et al., 2017). Some studies showed that effective error management positively influences organizational performance (Cannon and Edmondson, 2001; van Dyck et al., 2005), increasing the adoption of safety behavior that facilitates learning from errors and avoiding them in the future (Cigularov et al., 2010).

Safety culture is defined as the sum of individual and group values, attitudes, perceptions, competencies and behavioral patterns that determine organizational safety management commitments, styles and capabilities (de Oliveira, 2009). Developing a safety culture is a core element of many efforts to improve patient safety and care quality across care settings (Shekelle et al., 2013). This culture relates to various aspects, such as error reporting (Braithwaite et al., 2010; Elkin et al., 2016; Singh and Sittig, 2016), nonpunitive responses to errors, communication openness (Colla, 2005; Nieva, 2003), error feedback (Nieva, 2003), the reduction of adverse healthcare events (Mardon et al., 2010; Singer et al., 2009) and healthcare policies, procedures and leadership (Colla, 2005). However, the concept of safety culture concerning errors can also be referred to as error management culture (EMC). Van Dyck et al. (2005) identified the EMC as norms and common practices shared and applied within an organization concerning error communication, detection, reporting, analysis and correction, to identify possible causes and enable learning from them (Van Dyck et al., 2013).

Incident reporting is an essential component of EMC, allowing healthcare providers to be quickly alerted to patient safety risks (Elder et al., 2007). Despite this, healthcare professionals are regularly inhibited from reporting errors due to organizational factors such as a culture of blame (Kaissi, 2006) and a fear of retribution, punishment and professional humiliation (Force et al., 2006). Consequently, since error reporting decreases the likelihood of error reoccurrence (Antony et al., 2018; Scott Beattie et al., 2018), the development and promotion of an effective reporting system with a focus on improvement and not individual blame is critical (Archer et al., 2017; Gong et al., 2017; Trbovich and Vincent, 2019).

Previous research has shown that nursing leadership plays a key role in improving professional well-being and health (Cummings et al., 2018), promoting a positive work environment and supporting nursing practice (Boamah et al., 2018) or implementing new care models and providing high-quality patient care (Akbiyik et al., 2020; Wong and Giallonardo, 2013). These factors ensure positive outcomes for healthcare organizations (Specchia et al., 2021). Moreover, leadership style is crucial in the development of EMC (Ko and Yu, 2017). Studies in the nursing field have confirmed that head nurses’ leadership styles influence the promotion and development of a culture oriented toward early error detection, reporting and reflection (Farnese et al., 2019).

Therefore, promoting a safety culture through nursing leadership can have a fundamental effect on patient safety and incident reporting (Yusuf and Irwan, 2021). Conversely, research has also reported that head nurses with negative attitudes about patient safety-related issues or who sustained the importance of patient safety but failed to share such an attitude with their subordinates obtained worse care and organizational outcomes (Ridelberg et al., 2014). Potential errors and harm can be reduced through the promotion of safety and error culture in healthcare organizations, which, in turn, may decrease treatment and hospitalization times and improve or maintain patients’ functional status and well-being (Alves Barros et al., 2014). Patient safety must be a day-to-day priority in nursing leaders’ leadership style, as promoting a safety culture can improve nurses' satisfaction and care quality (Farokhzadian et al., 2018).

Previous research has examined safety culture and error management as independent constructs, without evaluating the relationship between these concepts, leadership roles, professional performance and patient outcomes (Yusuf and Irwan, 2021). Nursing leadership should integrate and promote a safety culture and EMC to create a safe and productive working environment. Safety culture provides a foundation of safety principles and practices that guide everyday nurses' behavior (de Oliveira, 2009), while EMC encourages an effective approach to error management (Farnese et al., 2019). Together, these two concepts promote a working climate where safety is a priority for patients and errors are seen as opportunities for improvement, which can improve organizational performance and nurses' well-being. Accordingly, error management should not be limited to the mere implementation of incident reporting, but rather to the development, within the organization, of an EMC, promoted by nursing leadership with a proactive and preventive aim. However, to the knowledge of the present authors, no reviews have, to date, analyzed to what extent and which nursing leadership style is more closely linked to the concept of EMC in healthcare organizations.

Considering the above considerations, the purpose of this review was to identify and synthesize existing literature on relations between nursing leadership style, error management culture (EMC) and error reporting and rate. We aimed to answer the following questions:

Q1.

How does the nursing leadership style influence error management culture?

Q2.

Is there a relationship between the nursing leadership style and error reporting?

Q3.

Is there a relationship between the nursing leadership style and error rate?

Method

This review was conducted and is reported following the integrative review methodology (Aromataris and Munn, 2020) and the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) of the Joanna Briggs Institute (Moher et al., 2009).

Inclusion criteria

Types of participants.

Studies involving nurses providing direct care to patients in any clinical setting or nursing managers as participants were included. Studies conducted on samples of nursing students, assistants, administrative staff and mixed professionals (e.g. nurses and nursing assistants, or nurses and physicians) were excluded.

Concepts.

This scoping review investigated the combination of two concepts: leadership and error management. Regarding error management, studies dealing with the related concept of safety culture were included if they measured or concerned the management of medical errors. Indeed, error management culture, as a kind of organizational climate, relates to employees’ perceptions of organizational practices concerning communicating about errors, sharing error knowledge, helping in error situations and quickly detecting and handling errors (van Dyck et al., 2005). Leadership is then recognized as an important factor that exerts a profound effect on staff learning from mistakes and errors (Ye et al., 2018; Zhao, 2011).

Context.

This scoping review was limited to publications on leadership in nursing clinical practice, including all settings in which nurses provide direct patient care, such as hospitals, long-term care and home care.

Types of sources.

This scoping review considered all types of studies, including quantitative, qualitative and mixed-method study designs. Editorials and literature reviews were excluded.

Search strategy

Initially, a preliminary search was conducted in the PubMed database to identify sources on the topic with the following keywords: nurs*, leader* and error management. The words contained in the titles and abstracts of relevant sources and the index terms used to describe the sources were used to develop a full search strategy, which was then applied in searching six electronic databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Web of Science, Embase and EBSCO. The search keywords included: leader*, leadership style, nurs*, error culture, error management, EMC, safety culture and safety climate. Only articles published in English and Italian were considered for this review since these are the only languages the research team is proficient in. Pretesting research was conducted to refine the search strategy and evaluate the inclusion and exclusion criteria. The supplementary file to this study further details the search strategy used for each database.

Selection of the studies

Two researchers (EM and FZ) conducted the database research and exported the results to the free online systematic review screening software Rayyan. Duplicates were therefore removed, and each manuscript was blindly and independently evaluated by title and abstract. A pilot screen was conducted of approximately 5% of the articles, to ensure that all the researchers understood the inclusion and exclusion criteria. A third researcher (JF) was consulted in any cases of disagreement. Potential articles were read in full and independently by the researchers, and the final selection of articles was approved in a collegial manner.

Data extraction

Data were extracted from the articles included in the scoping review using a data extraction tool developed by the reviewers, following the indications of the Joanna Briggs Institute (JBI) Manual (Aromataris and Munn, 2020). The extracted data included the author(s), year and country of publication, research objectives, setting, sample, methodology, leadership style and key findings relevant to this review’s objectives.

Data synthesis

The extracted data were organized in a narrative summary and tables to analyze how the results related to the review objectives and questions, following the indications of the JBI Manual (Aromataris and Munn, 2020). Using tabular and visual mapping processes, the data were collated and grouped into key article characteristics. Afterwards, summary themes of the results were developed, into which the studies were placed according to their relevance to the identified thematic area.

Assessment of methodological quality

The manuscripts selected in the previous steps were assessed for methodological validity by three independent reviewers (EM, FZ and JF), before final inclusion in the review, using the critical appraisal criteria from the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies (Aromataris and Munn, 2020). Studies were rated as high quality if they satisfied more than 80% of the appraisal criteria, moderate quality if they satisfied 50–80% of the appraisal criteria and poor quality if they satisfied less than 50% of the appraisal criteria. Those rated as poor quality were excluded from the review, following the indications of the JBI Manual (Aromataris and Munn, 2020). Any disagreements arising between the reviewers were resolved through discussion.

Results

Review process results

As shown in the PRISMA flow diagram (Figure 1), 9,692 papers were pulled from the database search. After removing duplicates (n = 3,134), 6,558 publications were screened by title and abstract and 6,513 were excluded, of which 1,045 were reviews, 1,302 were editorials and 4,121 because they only considered the relationship between leadership and patient safety culture and were not concerned with errors. Of the remaining 45 articles, a further 32 were excluded, 2 for poor quality (O’Connor and Carlson, 2016; Tutiany et al., 2019), 3 for being written in the Korean language (Kim, 2013, 2015; Lee et al., 2021), 2 because they included health professionals other than nurses (ALFadhalah and Elamir, 2022; Lee et al., 2016), 1 because it included administrative staff (Van Dyck et al., 2013) and 24 because they did not correspond with the aim of the review to select only primary studies investigating the specific correlation between leadership style and error management. At the end of the above process, 13 articles were deemed eligible for final inclusion in the review.

Quality of the studies

In the quality assessment, all 13 studies were rated as moderate to high quality, with scores greater than 75% (Table 1). The identification of confounders and strategies to address them were appraisal criteria unsatisfied in most of the cross-sectional studies, leading to an assessment of moderate quality in 12 of the studies. Only the research carried out by Lee and Dahinten (2021) satisfied all of the criteria, receiving the highest quality score (100%) (Lee and Dahinten, 2021).

Study characteristics

The year of publication of the 13 studies included in the review ranged from 2007 to 2022. Three studies were conducted in North America (Farag et al., 2017; Vogus and Sutcliffe, 2007; Wong and Giallonardo, 2013), three in Europe (Farnese et al., 2019; Lappalainen et al., 2020; Mäntynen et al., 2014) and seven in Asia (Barkhordari-Sharifabad and Mirjalili, 2020; Chegini et al., 2020; Kim et al., 2020; Ko and Yu, 2017; Labrague, 2021; Lee and Dahinten, 2021; Mrayyan et al., 2022). Most of the studies (n = 12) were cross-sectional and one was longitudinal (Mäntynen et al., 2014). The settings of all the studies were hospitals, but they differed in terms of being single-centre studies (Farag et al., 2017; Mäntynen et al., 2014; Wong and Giallonardo, 2013) or multi-centre studies (Barkhordari-Sharifabad and Mirjalili, 2020; Chegini et al., 2020; Farnese et al., 2019; Kim et al., 2020; Ko and Yu, 2017; Labrague, 2021; Lappalainen et al., 2020; Lee and Dahinten, 2021; Mrayyan et al., 2022; Vogus and Sutcliffe, 2007). The sample sizes varied from 153 nurses (Kim et al., 2020) to 2,700 nurses (Mäntynen et al., 2014).

In the included studies, various leadership styles were examined concerning errors and error management: Barkhordari-Sharifabad and Mirjalili (2020) considered the head nurses’ ethical leadership style; Farnese et al. (2019), Mrayyan et al. (2022) and Wong and Giallonardo (2013) considered authentic leadership; Kim et al. (2020), Lappalainen et al. (2020) and Mäntynen et al. (2014) considered transformational leadership; Chegini et al. (2020) and Ko and Yu (2017) considered coaching leadership; Lee and Dahinten (2021) considered inclusive leadership; and Labrague (2021) considered toxic leadership. The remaining studies of Farag et al. (2017) and Vogus and Sutcliffe (2007) mentioned leadership without further specifying a particular style of leadership.

The majority of instruments used in the studies were concerned with the concept of safety culture. Indeed, the concept of error was often only measured as a sub-category of safety culture. However, certain studies considered error detection and reporting tools (Table 2), though these presented the important limitation of self-reported data.

Overall, the results of this literature review underline the relationship between nursing leadership styles and error management culture, encompassing the intention to report errors and the actual occurrence of nurses’ errors in clinical practice. Three themes emerged and were identified in response to the research questions: 1) leadership and error management culture; 2) leadership and the intention to report errors; and 3) leadership and error rate.

Leadership and error management culture

Six articles included in this review analyzed the relationship between leadership and patient safety culture or error management culture (Farnese et al., 2019; Kim et al., 2020; Labrague, 2021; Lappalainen et al., 2020; Mäntynen et al., 2014; Mrayyan et al., 2022; Vogus and Sutcliffe, 2007).

Mäntynen et al. (2014) showed a positive relationship between transformational leadership and safety culture, which appeared to increase attention to patients, error-related feedback and communication, with mean scores for these subscales in 2010–2011 ranging from 3.14 (SD = 0.76) to 3.48 (SD = 0.71). Moreover, a transformational leadership style in the management of nursing processes was related to the maintenance of high levels of quality and safety, and the encouragement of nurses to pay attention to therapy processes. In accordance, Lappalainen et al. (2020) found a moderate but statistically significant correlation between transformational leadership and total medication safety (r = 0.541, p < 0.001). Finally, Kim et al. (2020) showed that transformational leadership was positively associated with the perceived benefits of using a medication safety system (r = 0.17, p = 0.032) and the medication-error management climate (r = 0.55, p < 0.001), with the β of the medication-error management climate decreasing from 0.55 (p < 0.001) to 0.53 (p < 0.001) to the perceived benefits of using the system. In Mrayyan et al. (2022), a significant positive moderate association was found between authentic leadership and the safety climate (r = 0.539). Perceptions, at the three hospitals examined, varied across different work areas and types of hospitals. Moreover, the study found that most adverse events are caused by system failures, not by a single individual’s actions. Nevertheless, improving nurse-leader interactions was found to be important, suggesting that open communication should be encouraged. Similarly, indirect effects of EMC were confirmed in the relationship between authentic leadership and the occurrence of nurses’ errors (Farnese et al., 2019), suggesting that a head nurse with a more authentic leadership style is better able to reduce the number of errors in his or her ward if he or she can create an organizational environment oriented to EMC. In agreement, Vogus and Sutcliffe (2007) also found that a trusting relationship between head nurses and nurses increased the benefits of safe practice and reduced adverse patient events. Moreover, when nurses highly trusted their managers, the benefits of safety organizing improved (β = −0.68, p > 0.001). In particular, the authors showed that when high levels of safety organizing are coupled with trusted leadership, wards report fewer medication errors.

Leadership and the intention to report errors

A second theme that emerged from this review was the relationship between leadership and the intention to report errors (Chegini et al., 2020; Farag et al., 2017; Ko and Yu, 2017; Lee and Dahinten, 2021).

In the study of Farag et al. (2017), leadership style and a climate of warmth accounted for a significant amount of variance in all safety climate dimensions, accounting for 20% regarding error feedback, 22% regarding organizational learning, 23% regarding nonpunitive responses to errors, 30% regarding communication openness, 45% regarding managers’ safety actions and 52% regarding teamwork. All leadership styles and a climate of warmth indirectly (through the safety climate dimension of nonpunitive responses to errors) explained 2% of the variance regarding nurses’ willingness to report medication errors, while transactional and passive-avoidant styles were found to hinder the development of a non-punitive environment. Although the transactional leadership style was positively associated with a safe climate, organizational learning, error feedback and a nonpunitive environment (Farag et al., 2017), nurses felt that associating a reward with performance (which is one of the attributes of transactional leadership) may contribute to the development of a punitive environment. This was confirmed by other authors who reported a positive correlation between nurses’ perceived level of coaching and their intention to report errors (Chegini et al., 2020; Ko and Yu, 2017).

Another important result of Chegini et al. (2020) was the significant association between nurses’ intention to report errors and the level of their education. Nurses with an associate degree level education were 80% more likely to report errors than those with a Bachelor’s, master’s or doctorate. An increase of 20% in the intention to report errors was observed for a one-unit increase in the patient safety culture score. Similarly, a one-unit increase in the leader coaching behavior score was accompanied by a 20% increase in the intention to report errors.

Moreover, Lee and Dahinten (2021) showed that nursing managers’ inclusive leadership was positively associated with nurses’ psychological safety, speaking up and error reporting intention, and negatively associated with withholding one’s voice. Indeed, leader inclusiveness helps nurses to feel psychologically safe, allowing them to speak up more freely and disclose errors, thus creating more opportunities to improve patient safety. Such leadership gives nurses opportunities to ask questions and discuss patient safety concerns and establishes a climate of psychological safety in which nurses feel encouraged to report errors.

Finally, another important result that emerged from this literature review was that nurses felt that if they reported errors they had committed, these would be held in their files and might be used against them at some point in the future, and, for such a reason, they often preferred to not report their errors (Chegini et al., 2020; Farag et al., 2017). On the other hand, when managers used errors to prevent them from happening again, nurses were encouraged to report errors and to develop a safety climate dimension of organizational learning and error feedback (Farag et al., 2017).

Leadership and error rate

Four studies analyzed the relationship between leadership and error rate (Barkhordari-Sharifabad and Mirjalili, 2020; Farnese et al., 2019; Labrague, 2021; Wong and Giallonardo, 2013).

Considering the relationship between leadership and errors involving patients, it emerged that authentic leadership was associated with more trust in managers and areas of work life, and, importantly, lower frequencies of adverse patient outcomes (Wong and Giallonardo, 2013). When nurses’ managers employ authentic leadership, patient adverse outcomes, such as nosocomial infections and falls, are reduced significantly. Conversely, Labrague (2021) found a strong and significant association between toxic leadership and poor care quality, including patient and family complaints (β = 0.619; p < 0.001), patient and family verbal abuse (β = 0.407; p < 0.001), patient falls (β = 0.834; p < 0.001), nosocomial infections (β = 0.629; p < 0.001) and medication errors (β = 0.708; p < 0.001). Another study saw a reverse statistically significant correlation between ethical leadership and error rate. In the presence of ethical leadership, the findings showed that, during the 6 months of observation, the mean total nursing error rate was lower than the average (36.49 ± 9.47), with a mean ± SD of error reporting of 44.83 ± 12.43 (Barkhordari-Sharifabad and Mirjalili, 2020). Furthermore, a relationship was seen between the nursing error rate and gender, higher in men (39.50 ± 39.88) than in women (34.28 ± 8.61), but not between the nursing error rate and other demographic variables. Farnese et al. (2019) also found that, through error management culture, an authentic leader was associated negatively with the number of errors (slips/lapses: β = −0.16, bootstrap 95% CI = −0.226 − 0.098, mistakes: β = −0.145, bootstrap 95% CI = −0.211 − 0.085). In fostering a work environment oriented to the management of errors and learning from them, head nurses were observed to promote the sharing of an EMC among nurses, and, consequently, to reduce the number of errors in clinical practice (Farnese et al., 2019).

Discussion

The objective of this scoping review was to examine the relationship between nursing leadership style, error management culture and errors. The impact of head nurses’ leadership style was thus analyzed about error management culture, the intention to report errors, and the number of errors committed by nurses in clinical practice. In general, the results show that nursing leadership has a key role in establishing error management culture, in facilitating the reporting of errors and near misses with the potential to affect patients’ outcomes and indirectly impact the occurrence of errors.

Regarding error management culture, nursing leadership is certainly fundamental in fostering, establishing and preserving a work environment and organizational culture (Van Dyck et al., 2013). Specific leadership styles encourage changes in the work environment and have been associated with error management culture (McFadden et al., 2009). Among these, consistent with other studies in the literature (Goldstein et al., 2017; Merrill, 2015; Yusuf and Irwan, 2021), we were able to identify transformational and authentic leadership. Transformational leaders are charismatic, demonstrate high standards of ethical and moral conduct and are trusted, respected and admired (Lappalainen et al., 2020). Furthermore, transformational leaders use idealized influence, inspiration and motivation, intellectual stimulation and individualized consideration to achieve superior results (Hayati et al., 2014) and promote team and organizational interests (Trastek et al., 2014). It is particularly important to encourage good error management in transformational leaders because this can then have a knock-on effect on nurses’ thoughts, performances and improved results and outcomes for patients (Goldstein et al., 2017; Huber, 2018). A favoring head nurse leadership style, as well as a transformational one, promotes a nonpunitive and proactive error management climate in which nurses, not fearing repercussions, feel happier and freer to report errors, leading to a decrease in adverse events and errors (Lappalainen et al., 2020; Mäntynen et al., 2014). The other leadership style evaluated in association with error management culture is authentic leadership. An authentic head nurse is capable of influencing the perceptions and opinions of nurses (Farnese et al., 2019; Mrayyan et al., 2022). This leadership style is characterized by a distinctive approach to justice and support (Avolio and Gardner, 2005). Moreover, this nursing leader is more ethical, and transparent in the leader-follower relationship, and recognizes the importance of individuals’ processes of knowing and understanding themselves and others (Laschinger and Fida, 2015; Wong and Cummings, 2009). Therefore, authentic leadership seems to be key to making a difference in nurses’ views on error management culture (Mrayyan et al., 2022).

Another finding that emerged from this literature review was the relationship between nursing leadership and nurses’ intention to report errors. A good leader encourages the reporting of errors because he or she recognizes the importance of proactive behavior (Chegini et al., 2020; Ko and Yu, 2017), of listening to nurses about errors in judgment (van Dyck et al., 2005) and of learning from errors to prevent their reoccurrence (Frese and Keith, 2015). The reporting of errors is influenced by the personal characteristics of the reporting individuals, such as personality type and self-confidence. However, trust in the organization they are part of can make a significant difference (Farag et al., 2017), and, in this, nursing leadership, in care teams, is crucial. Staff must be able to trust their leader, trust that errors will be handled justly, and trust that the individuals reporting their errors will be treated fairly and will not suffer punishment (Wang and Dewing, 2021).

There are also studies demonstrating that trust in a leader and the psychological condition that nurses report about their operating unit (proactive or punitive regarding errors) are mediators between errors happening and the intention to report them (Lappalainen et al., 2020; Wong et al., 2010). Several leadership styles are particularly effective in establishing a climate in which nurses report errors, such as the coaching style (Chegini et al., 2020; Ko and Yu, 2017), the inclusive style (Lee and Dahinten, 2021), the transactional style and passive avoidant leadership style (Farag et al., 2017). These leadership styles have a positive impact on patient safety and outcomes because they create and stimulate a work environment based on self-learning, proactive error management, time for reflection on improving team performance and support for nurses in their professional practice (Wang and Dewing, 2021).

Despite the efforts made by organizations to improve patient safety, errors still happen, and the resulting adverse outcomes continue to be one of the major problems in nursing and healthcare. This literature review verified that particular styles of nursing leadership in inpatient wards have a measurable relationship with the number of errors that occur. Among these styles, we verified that the ethical leadership style (Barkhordari-Sharifabad and Mirjalili, 2020) and the authentic leadership style (Wong and Giallonardo, 2013) have been seen to be effective and able to create working conditions that support professional, quality nursing practice and reduce the frequency of adverse events (Labrague, 2021).

On the contrary, a toxic leadership style is positively correlated with poor quality of care by nurses, verbal abuse by nurses, falls, nosocomial infections, and medication administration errors (Labrague, 2021). This could be because a toxic leadership style, with leaders perceived to be motivated solely by self-interest, insensitive to the human (individual and social) side of the working environment and able to negatively affect the team’s social, organizational and behavioral climate seem to generate work environments in which people work with fear and set wrong examples (Low et al., 2021; Sharif Nia et al., 2022). All this can lead to insecurity and reduced self-efficacy (Pillai and Williams, 2004), which can impact nursing performance by inducing a greater propensity for errors (Vancouver et al., 2002).

Limitations

Despite the important findings of this scoping review, some limitations must be considered. Firstly, only English language studies were included, possibly excluding other potentially relevant studies in other languages that could have important information. Secondly, all the studies included in the review used self-reported data, introducing a potential response bias and limitations due to the possible nonobjectivity of the data. Future studies should therefore consider the use of more objective error measurement systems, such as official incident reporting data sets. Moreover, the occurrence of errors is often analyzed not as a single concept but in association with patient safety. This association may not allow the concept of errors to be fully analyzed, such as in examining specific types of error (e.g. slip, lapse, mistake). Finally, the included studies were carried out in various cultures, which have different ideas and expectations on the nature of leadership (Barkhordari-Sharifabad and Mirjalili, 2020; Ko and Yu, 2017), the culture of safety and punitive work climates (Ko and Yu, 2017). For this reason, it is challenging to identify common ways of thinking about the concepts under examination, and more research should therefore be carried out.

Conclusion

This review aimed to retrieve and synthesize existing literature on the relationship between nursing leadership style, error management culture and errors. Overall, it was possible to verify that head nurses should adopt a positive, nonpunitive and proactive approach to error management in their leadership style. The reduction of errors and near misses in nursing settings should be a goal of all healthcare organizations, even if it is impossible for them not to occur at all. The results of this review underline the necessity of learning from errors to prevent them and limit their effects on patient safety.

Medical errors cause patient injuries across the world, and the role of head nurses is to adopt an appropriate and positive leadership style that facilitates the reporting of errors and prevents their reoccurrence. Under such conditions, outcomes for patients and their families are improved, and nurses have a better work-life in their units and organizations (Chegini et al., 2020). At a time when nursing is facing shrinking economic resources and potential shortages, nursing leadership is key to promoting and maintaining a positive work environment, engaging nurses personally and professionally, and, finally, contributing to better patient outcomes (Wong and Giallonardo, 2013). Future research is needed on these topics to further explore the relationship between nursing leadership style, error management culture and errors. However, the results of this review do underline that the managers of healthcare organizations should promote training dedicated to head nurses and their leadership style, to create a good work environment (proactive and non-punitive) in which nurses feel free and empowered to report errors, and learn from them, and prevent their reoccurrence in the future.

Figures

Figure 1.

PRISMA flow diagram of the review process

Table 1.

Summary of quality assesment

Quality appraisal criteria	Vogus and Sutcliffe, 2007	Wong and Giallonardo, 2013	Mäntynen et al., 2014	Ko and Yu, 2015	Farag et al., 2017	O’Connor and Carlson, 2016	Farnese et al., 2019	Tutiany et al., 2019	Barkhordari-Sharifabad and Mirjalili, 2020	Chegini et al., 2020	Kim et al., 2020	Lappalainen et al., 2020	Labrague, 2021	Lee and Dahinten, 2021	Mrayyan et al., 2022
Were the criteria for inclusion in the sample clearly defined?	y	y	y	y	y	n	y	n	y	y	y	y	y	y	y
Were the study subjects and the setting described in detail?	y	y	y	y	y	n	y	y	y	y	y	y	y	y	y
Was the exposure measured in a valid and reliable way?	y	y	y	y	y	y	y	n	y	y	y	y	y	y	y
Were objective, standard criteria used for measurement of the condition?	y	y	y	y	y	y	y	n	y	y	y	y	y	y	y
Were confounding factors identified?	n	n	n	n	n	n	n	n	n	y	n	n	n	y	n
Were strategies to deal with confounding factors stated?	y	n	n	n	n	n	n	n	n	n	n	n	n	y	n
Were the outcomes measured in a valid and reliable way?	y	y	y	y	y	y	y	n	y	y	y	y	y	y	y
Was appropriate statistical analysis used?	y	y	y	y	y	n	y	n	y	y	y	y	y	y	y
Overall quality assessment (%)	87.5	75	75	75	75	37.5	75	12.5	75	87.5	75	75	75	100	75

Source: Authors’ own work

Table 2.

Characteristics of included studies

Authors	Aims	Design	Context	Sample	Leadership style	Results
Vogus and Sutcliffe, 2007 USA	To examine the benefits of bundling safety organizing with leadership (trust in manager) and design (use of care pathways) factors on reported medication errors	Cross-sectional	Multicentre study in 10 acute care hospitals	1,033 nurses, 78 nurse managers	Leadership in general	The interaction effects between safety organizing and trusted leadership and safety organizing had significant effect (β = − 0.68, p > 0.001); also in the care pathway, there were negative relationships with reported medication errors. The benefits of increasing safety organizing are more pronounced when associated with high levels of trust in one’s manager and extensive use of care pathways on a unit
Wong and Giallonardo, 2013 Canada	To examine the effect of authentic leadership on nurses’ perceptions of the incidence of adverse patient outcomes and how it influenced adverse outcomes through the mediators, trust in the manager and nurses’ perceptions of the quality of the work environment	Cross-sectional	Monocentric study	280 nurses	Authentic leadership	Authentic leadership was significantly associated with decreased adverse patient outcomes through trust in the manager and areas of work life. Authentic leadership could reduce patient adverse events through modifying nurses’ workplace condition that foster nurses’ trust in them and manager
Mäntynen et al., 2014 Finland	To describe the changes in transformational leadership and empirical quality outcomes, specifically, job satisfaction among nurses, patient safety culture and patient satisfaction	Longitudinal	Monocentric study	2,700 nurses	Transformational leadership	Evidence-based leadership training has a positive impact on nursing staff, but it must be available to all leaders. The mean scores for the following patient safety culture increased between two measurements [from 3.14 (SD = 0.76) to 3.48 (SD = 0.71)]): overall perception of patient culture, error-related feedback and communication, events reported and nonpunitive responses to errors
Ko and Yu, 2017 Korea	To examine the correlation among nurses’ perception of patient safety culture, their intention to report errors and leader coaching behaviour	Cross-sectional	Multicentre study	289 nurses	Leadership coaching	High manager performance reports a positive perception of safety culture and intention to report errors. A coaching program helps the leader, improve their skills for human resource management and patients’ safety; it also requires staff to be empowered and a good level of communication to exist within and between employee levels
Farag et al., 2017 USA	To examine the leadership style and unit climate to predict safety climate; and to test the direct, indirect and total effect of leadership style, unit climate and safety climate on nurse’s safe medication practices	Cross-sectional	Monocentric study 5 critical care and 11 medical – surgical units	246 nurses	Leadership in general	All leadership styles and work climate follow availability to report errors. Leadership style and warmth climate explained a significant amount of variance in all safety climate dimensions; they explained 20% of error feedback, 22% on organizational learning, 23% of nonpunitive response to error, 30% of communication openness, 45% of managers safety actions and 52% of teamwork; all leadership styles and warmth climate indirectly (through safety climate dimension of nonpunitive response to errors) explained 2% of variance on nurses willingness to report medication error. Although the transactional leadership style was positively associated with a safe climate, organizational learning, error feedback and a nonpunitive environment, nurses felt that associating a reward with performance can contribute to the development of a punitive environment
Farnese et al., 2019 Italy	To explore whether and how authentic leadership could represent a relevant factor in supporting a positive cultural orientation towards error management, which would in turn reduce the occurrence of errors	Cross-sectional	Multicentre study in 4 hospitals teaching, rehabilitation, public, accredited private)	286 nurses	Authentic leadership	Authentic leadership was positively related to errors by promoting a work environment oriented towards the management of errors and learning from them. Authentic style can promote policies and practices to proactively manage errors, paving the way to error reduction in the workplace and focusing on the final phase of the error-handling proces
Barkhordari-Sharifabad and Mirjalili, 2020 Iran	To determine the level of ethical leadership and its dimensions from nurses’ point of view and its effect on nursing errors and error reporting	Cross-sectional	Multicentre study Medical – surgical wards	171 nurses	Ethical leadership	There was a statistically significant relationship between nursing managers’ level of ethical leadership with error rates and reporting. The level of nursing managers' ethical leadership was moderate from the nurses' point of view. The highest and the lowest levels were related to the power-sharing and task-oriented dimensions, respectively
Chegini et al., 2020 Iran	To explore the association between PSC, nurses’ intentions to report errors and the coaching behaviour of leaders	Cross-sectional	Multicentre study: emergency departments	350 nurses	Coaching leadership	In a hospital where management does not provide a supportive working environment in the promotion of patient safety, the nurses choose not to report errors for fear of stigmatization, blame and punishment. Moreover, a statistically significant difference was shown between the educational level of nurses and their intention to report errors
Kim et al., 2020 Korea	To investigate the mediating role of the perceived benefits of using a medication safety system in the relationship between transformational leadership and the medication-error management climate	Cross-sectional	Multicentre study 11 secondary or tertiary hospital	153 nurses	Transformational leadership	Transformational leadership was positively associated with benefits of the system use (r = 0.17, p = 0.032) and a best medication error management climate (r = 0.55, p < 0.001), with the benefits of system use, the β of the medication EMC decreased from 0.55 (p < 0.001) to 0.53 (p < 0.001). The benefits for use the system had a mediating effect between transformational leadership and medication error management culture
Lappalainen et al., 2020 Finland	To evaluate medication safety, transformational leadership and their relationship as experienced by registered nurses in three Finnish hospitals	Cross-sectional	Multicentre study	1,002 nurses	Transformational leadership	There was a statistically significant correlation between transformational leadership and medication safety (r = 0.541, p < 0.001). A transformational leadership style in the management of nursing processes is important to the maintenance of high-quality care and patient safety, on medication therapy processes
Labrague, 2021 Philippines	To examine the relative impact of toxic leadership shown by NMs on nurse-reported quality of care and adverse events	Cross-sectional	Multicentre study	1,053 nurses	Toxic leadership	Nurse managers’ toxic leadership behaviours were associated with increased nurse reported adverse events including complaints (β = 0.619; p < 0.001), patient and family verbal abuse (β = 0. 407; p < 0.001), patient falls (β = 0.834; p < 0.001), nosocomial infections (β = 0.629; p < 0.001) and medication errors (β = 0.708; p < 0.001)
Lee and Dahinten, 2021 South Korea	To investigate the relationship among inclusive leadership, psychological safety and three nurse outcomes—speaking up, withholding voice, and error reporting intention	Cross-sectional	Multicentre study: medical – surgical units	731 nurses	Inclusive leadership	Inclusive leadership was positively associated with nurses’ psychological safety, speaking up and error reporting intention, and negatively associated with withholding voice
Mrayyan et al., 2022 Jordania	To compare Jordanian nurses’ perceptions of authentic leadership and safety climate perceptions based on areas of work, types of hospitals, area of work and types of hospitals	Cross-sectional	Multicentre study: governmental, private and military	316 nurses	Authentic leadership	A significant positive moderate to high association between nurses’ authentic leadership and safety climate perceptions (r = 0.539). Authentic leadership should be used as a guide to ensure positive outcomes

Source: Authors’ own work

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