Relationship Between Nursing Leadership and Quality of Care in ICUs: Mediating Through Patient Safety Culture

Introduction: Providing safe and high-quality patient care is a fundamental principle of health care. According to a national study (Liu, You, Zheng, Ross & Liu, 2016), 23% of nurses perceived poor patient care quality, and 16-24% reported frequent adverse events in intensive care units (ICUs) in China. The quality of patient care still needs to be improved in ICUs. Recent studies indicated that nurse managers’ strong leadership was positively associated with quality of care (Wong & Giallonardo, 2013; Laschinger & Fider, 2015; Boamah et al., 2017). Patient safety culture is also associated with higher quality of care and better patient outcomes, and is regarded as a mediator in the relationship between leadership and patient outcomes (McFadden, Stock & Gowen, 2015; Dirik & Seren Intepeler, 2017). As those relationships have not been tested in ICUs, the generalizability of enhancing leadership to improve quality of care in ICUs might be limited.

Objectives: To investigate the relationship between nurse managers’ supportive leadership and quality of care in ICUs, and to explore the mediating role of patient safety culture in these relationships.

Hypotheses: nurse managers’ supportive leadership will be positively associated with patient safety culture and quality of care; and patient safety culture will be positively associated with quality of care; and patient safety culture will mediate the relationship between nurse managers’ supportive leadership and quality of care.

Methods: This study was conducted in Dec 2013 to Aug 2014, adopting cross-sectional design. Twenty-two adult ICUs in 23 hospitals across Guangdong province in China were selected by quota sampling. All bedside nurses in the selected ICUs were invited to participate, except for nurse managers. A total of 527 nurse surveys were distributed, and 498 were returned, among which 459 were valid responses (valid response rate: 87.1%). The nurse manager’s ability, leadership and support subscale of Practice Environment Scale of Nursing Work Index was used to assess nurse-perceived managers’ leadership behaviors. Quality of care was measured with three items about nurse-rated overall quality of care on their units (i.e., the quality of care, patient safety and confidence on nurse manager solving patient care problems). Nurses-reported frequencies of hospital-associated infections (HAIs) were measured by asking nurses to recall the frequencies of four types of HAIs (i.e., surgical site infection, urine tract infection, central line-associated bloodstream infection, and ventilator-associated pneumonia) in the last 12 months. Patient safety culture was measured with seven items derived from the Hospital Survey on Patient Safety Culture, assessing whether work units regulations, managers and communications were beneficial to improve patient safety. Structural equation modeling with robust maximum likelihood estimator was used to estimate the direct and indirect relationship among nurse managers’ supportive leadership, patient safety culture and quality of care. The Mplus version 7.2 was used for model testing.

Results: The hypothesized model fit data well (RMSEA = .037, CFI= .979, TLI= .972). Nurse managers’ supportive leadership had direct positive effects on patient safety culture (β= .472, p<0.01) and nurse-rated overall quality of care (β= .330, p<0.01); however, the direct effects of leadership on HAIs was not significant (β= .010, p=0.87). Patient safety culture had direct positive impacts on nurse-rated overall quality of care (β= .326, p<0.01) and negative impacts on HAIs (β= - .28, p<0.01). Through the mediation of patient safety culture, supportive leadership was associated with higher quality of care (β= .154, p<0.01) and less HAIs (β= -.132, p<0.01) indirectly.

Conclusion: Supportive leadership plays an important role in creating patient safety culture that foster high-quality care in ICUs. ICU nurse managers are encouraged to develop supportive leadership skills and to dedicate to build work culture that initiate patient safety.