The Role of Leadership of Head Nurses in Implementing a Culture of

Patient Safety Applied by Associate Nurse in Public Bekasi Hospital

Nur Miladiyah R and Puji Sarwati

STIKes Bani Saleh, Bekasi, Indonesia

Keywords: Leadership, Patient Safety, Culture.

Abstract: The need to improve the culture of patient safety in hospitals was very imperative. The efforts to implement

safety culture has been affected by the role of the leadership. This study aimed to determine the role of

leadership of the head nurse to apply the patient safety culture in the ward. The research design used a

correlations analytics with a cross-sectional approach to 155 clinical nurses as the samples in Public

Hospitals Bekasi. The questionnaire used a Hospital Survey On Patient Safety Culture (HSOPSC) from The

US Agency For Healthcare Research and Quality (AHRQ). Data analysis used a Pearson, Spearman, t

independent and linear regression. The result of the linear regression equations was obtained by the

increasing of the leadership role of the head nurse. It was 86,309 after controlling 1,971 times organizational

support and 1,512 times the supervisors of head nurses implemented a patient safety culture. This study

recommendation was the improvement of the capability of the head nurse which was related to the

leadership function and it gave the relevant reward system based on patient safety culture.

1 INTRODUCTION

Hospitals as the most important element of the

healthcare systems, are aimed to provide high-

quality care to patients (Ghahramanian, Akram;

Rezai, Tayyebeh, 2017). Safety culture refers to the

way patient safety is thought about and implemented

within an organization and the structures and

processes in place to support this (Health

foundation, 2011). Leadership competencies around

patient safety are intended to identify and establish

skills common to nurses (Parand, A; Dopson, S,

Renz, A 2014). Patient safety is a cultural

transformation. A leader with his leadership can

make a cultural change towards the success of a

patient safety program (Hewitt, D.B; Goldstein,Scott

D; Isenberg., 2017). This attention because

leadership is an important element in creating a

strong culture in implementing patient safety

(Parand, A; Dopson, S, Renz, A 2014). Fleming and

Wentzell, (2008) notes the safety culture influences

by motivating healthcare professionals to choose

behaviors that enhance, rather than reduce, patient.

Fleming and Wentzell, (2008) states identify the

following patient safety culture elements are

leadership commitment to safety, organizational

resources for patient safety, a priority of safety

versus production, effectiveness, and openness of

communication.

Safety culture properties include leadership,

communication, teamwork, management support,

continuous learning, and patient-centered care

(Aboshaiqah, Ahmad E; Hamdan Mansour, 2014).

Low safety culture is associated with many adverse

metrics such as increased length of stay, hospital

mortality (Hewitt, D.B; Goldstein,Scott D;

Isenberg., 2017)

Leadership in nursing is one of the factors that

influence the safety and quality of care in hospitals

(Schyns and Veldhoven, 2010). Safety leadership

means that the direct supervisor advocates values

inherent in safety and communicates this values to

the staff, by prioritizing patient safety procedures are

rewarded, open communications regarding mistakes

is encouraged and mistakes are responded to with a

fair evaluation of their causes (Livne, Y; Raskhovits

S, Peterfreund, Ilana S., 2017).

The concerning of the healthcare quality and

patients satisfaction through to the provision of high-

quality healthcare services is a must. Patient safety

incident at the public Hospital in Bekasi is the

presence of various unexpected events and near-

injury events that can threaten patient safety. The

Rahmah, N. and Sarwati, P.

The Role of Leadership of Head Nurses in Implementing a Culture of Patient Safety Applied by Associate Nurse in Bekasi General Hospitals.

DOI: 10.5220/0008222601810186

In Proceedings of the 1st International Conference of Indonesian National Nurses Association (ICINNA 2018), pages 181-186

ISBN: 978-989-758-406-0

181

patient safety culture is included the frequency of

event reporting, rating overall perceptions of safety,

nonpunitive response to error, and communication

due to the adverse events. Creating cooperation in

carrying out nursing care, reporting when there are

unwanted events, Therefore patient safety should be

a culture for us to be developed in the hospital, and

it requires support from the management function

and leadership of a head nurse in order to be able to

carry out supervision and control of patient safety

programs which is carried out by the nurses at

Bekasi Public Hospital. This study aims to

determine the role of the head nurse in implementing

a culture of patient safety applied by associated

nurse Bekasi Public Hospitals.

2 METHODS

This research design carried out the descriptive

correlation with cross-sectional. The study was

conducted in 2018. Data collection period was taken

from April to June 2018. The sampling population

was 302 nurses, and it was only 155 nurses who

were able to participate in the study. The

iinstruments used questionnaire Hospital Survey On

Patient Safety Culture (HSOPSC) from The US

Agency For Healthcare Research and Quality

(AHRQ) in 2011. It consisted of 42 statements about

the staff perceptions of patient safety culture under

the following domain: (1) supervisors expecting to

promote patient safety, (2) teamwork within units

(3) organizational learning continuous, (4)

management support for patient safety (5) feedback

and communication about error, (6)Frequency

reported, (7) teamwork across units, (8) Staffing, (9)

non punitive response to errors. Data was collected

by using a questionnaire which was included the

nurse characteristics, the role of leadership and the

patient safety culture. Data were analyzed by SPSS

21. It was considered as suitable software for data

entry, storage, and analysis. Descriptive statistical

analysis such as frequency counts, percentage, the

mean, median, and standard deviation was applied to

describe the research sample. The Pearson product

moment correlation coefficient was used to describe

the association between variables. Data analysis was

performed in linier regressions. Statistical

significance was set at p> 0,05. Before

administration of the questionnaires, informed

consent were taken from the participants. The ethical

clearance issued by the ethical committee Bekasi

Public Hospitals.

3 RESULT

3.1 Descriptive Statistic Characteristic

of Participants and Perceived the

Role Leadership

The characteristics of nurses included the age, the

gender and the length of service. The characteristics

of a nurse in the inpatient ward of public hospital of

Bekasi was presented in table 1.

Table 1: The characteristic of participants.

Variable Total Percentage (%)

Age

a. 20-32

b. 33-55

52.9

47.1

Gender

a. Male

b. Female

113

Lengths of Service

a. < 8 years

b. ≥ 8 years

104

Education

a. Diploma Nursing,

b. Nurse

103

Total 155 100

Characteristics of respondents age were 20-32

years (52.9%), female sex (73%), work period <8

years (67%), Diploma nursing (66%).

Table 2: Distribution the Role of Leadership.

Variable Mean SD

Minimum

Maximum

95% CI

Feedback and

communication

openness

50.5 6.86 33-109

49.45-

51.63

Teamwork

1.91 8-16

23.29 –

25.08

Organizational

10.11

1.38 7-12

9.89–

10.33

Management

suppor

5.63 16-86

12.54 –

13.15

Supervisors

expecting to

promote patient

safety

20.8

2.23 15-24

20.49-

21.19

Frequency reported

20.6

2.47 4-24

20.22-

21.01

Teamwork across

2.06 14-24

20.94-

21.60

Staffing

2.81 11-18

23.08-

23.97

Non punitive

response to errors

5.63 6-20

23.29-

25.08

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

182

Regarding the results shown the sub variable of

role leadership has the feedback and communication

openness was good with an average score 50.5, the

teamwork of the nurses was good with an average

score was 12, the organizational was applied fairly

well by the head of the ward with an average score

of 10.1. The management support of the head nurse

with an average score was 24. The supervisors

expecting to promote patient safety with an average

score was 50.5. Frequency reported with an average

score 20.6. The teamwork across with an average

score 21. The staffing with an average score 23. Non

punitive response to errors with an average score 16.

All the sub variable the role of leadership was

believed in 95%.

Table 3: distribution of patient safety culture by associate

nurse’s.

Variable

Mean

Median

Patient safety culture

137.76

139.00

10.094

Based on the results, the patient's safety culture

of associate nurses with an average score was 137.76

and the median score was 139.00 and the standard

deviation was 10.094.

3.2 The Correlations the Role of

Leadership of Head Nurses in

Implementing a Culture of Patient

Safety Applied by Associate Nurse

in Public Hospital Bekasi

Table 4: The Correlations the role of leadership with the

patient of safety culture.

No. Variable

Patient safety culture

R Sig

1. Age 0.057 0.479

Supervisors

expecting to

promote patient

safety

0.151 0.060

3. Teamwork 0.224 0.005

4. Organizational 0,371 0.000

Management

suppor

0.378 0.000

Feedback and

communication

openness

0.242 0.002

Frequently

reported

0.208 0.009

8. Teamwork across 0.122 0.129

9. Staffing 0.081 0.129

10.

Non punitive

response to errrors

0.285 0.000

Based on the table above, five sub variable has

corelations with the patient safety culture, there are;

teamwork (pvalue; 0.005, α=0.005) , organizational

(pvalue; 0.000, α=0.005), management support

(pvalue 0,000, α=0.005), Feedback and

communications openness (pvalue; 0.002, α=0.005),

and non punitive response to errors (pvalue; 0.0000,

α=0.005). The next step is to include sub-variables

related to the patient safety culture into multivariate

analysis.

Table 5: Final Model of Multivariate analysis.

Variable

Unstandardize

Coefficients

Standard

Coeficient

Sig

BSE B

Constan

86.309 8.150 0.000

Organizational

suppor

1.971 0.530 0.271 0.000

Supervisors

expecting to

promoting

patient safety

1.512 0.329 0.334 0.000

According to our findings, the organizational

support and the supervisors has significance

relatiaonship role leadership to the culture of patient

safety (pvalue 0.000, α=0.005).

Based on table 5, the result showed

organizational support and had significant

correlations (pvalue> 0.005). The constant 86,309 of

patient safety culture by an associated nurse was

1,971 times after being controlled by supervisions of

head nurses to promoting patient safety.

Figure 1: The nurse applied the patient safety culture with

controlling of the organizational support and supervisors

expecting to promote patients safety.

The final results of linear regression, Y’= a +bX

The Role of Leadership of Head Nurses in Implementing a Culture of Patient Safety Applied by Associate Nurse in Bekasi General Hospitals

183

The implementation of a patient safety culture =

86.309+1.97 organizational support +1,512

Supervisors expecting to promoting patient safety.

4 DISCUSSION

The study examined the role of leadership of head

nurse in Implementing a Culture of Patient Safety by

an associate nurse in Public Bekasi Hospitals. Based

on the result showed organizational support had

significant correlations (pvalue > 0,005). The

constant 86,309 of patient safety culture by an

associated nurse was 1,971 times after being

controlled by supervisions of head nurses to

promoting patient safety. Regarding the results,

organizational support had significant correlations

with the patient safety culture. Parker et al (2006) in

(Fleming and Wentzell, 2008) said that safety

culture was affected by organizational changes, such

as a change in leadership or in the introduction of

new systems and process. With regard to the patient

safety culture, the highest scores in our study related

to the organizational support for patient safety. The

organizational support was included the nonpunitive

responses to errors and staff working issues

(Ghahramanian, Akram; Rezai, Tayyebeh, 2017).

Leaders could build safety cultures by

participating readily and willingly with care team

members in initiatives designed to develop a safety

culture. (Hewitt, D.B; Goldstein,Scott D; Isenberg.,

2017). Effective leaders who deliberately engaged in

strategies and tactics to strengthen their

organization’s safety culture. Kundu, Yadav and

Yadav, (2016) it was shown that the safety issues

became the problems within the organizational

systems. It was not about their employees, adverse

events and close calls (“near misses”) as providing

“information-rich” data for learning and systems

improvement (Bahadori A, Peyrovi H, Ashgali-

Farahani M 2016). Organizational commitment and

leadership were the foundation for mitigating patient

harm (Sherwood, 2015). Leaders were critical to an

organizational’s successful development of a culture

safety (Setiowati, D 2010). The individuals within

the organization respect and were wary of

operational hazards, had collective mindfulness that

people and equipment will sometimes fail, defer to

expertise rather than a hierarchy in decision making,

and develop defenses and contingency plans to cope

with failures (Ehrmeyer, 2011). The culture was a

product of what was done on a consistent daily

basis. (Sammer C, Lykens K, Singh 2010). Hospital

team members measured an organization’s

commitment to culture by what leaders did, rather

than what they saw or should be done (Pronovost P,

Berenholtz S, Goeschhel C., 2008).

Safety culture in health services was defined as

beliefs, values, and behaviors associated with the

safety of patients who were consciously shared by

members of the organization including

implementing nurses who were directly seen in

providing safe nursing care to patients. (Hall and

Moore, 2008). The patient safety culture was

important because it built the overall culture of

patients (Cummings G.G., MacGregor T., Davey M.,

Wong C.C, Lo E, Muise M., Stafford E.,(2010).

Building awareness of the value of patient safety,

creating an open and fair leadership and culture was

the first step in implementing patient safety (Health,

2010). The measurement of patient safety culture

helped the leader to know the data needed in

implementing the patient's safety program so that the

leader could design and implement patient safety

designs that were in accordance with the data found

(Adler, L David Y; Michael L, Marry Mc Broom.

(2015). Leadership was an important component that

assures organizational quality health care services,

patient satisfaction and financial performance.

Moreover, nurses perception of their ability to

manage patients health needed appropriately

(Sherwood, 2015). The results suggested that the

supervisors expecting to promote patient safety

would be increased by the number of applied nurses

to implement patient safety culture. Whereas strong

leadership was often cited as critical to an

organization”s culture of safety (Safety and

Components, 2017). Leaders requires basic insights

into safety problem and need rationals for focusing

on patient safety (Sammer C, Lykens K, Singh

(2010).

Regarding Change, (2010), the leadership of

competency models should consist of the core

patient safety technologies competencies, patient

safety leadership competencies and culture of safety

competencies. The three component results practiced

environments of safety. Supervisors in promoting

patient safety were intended to identify and establish

skills common to nurses in executive practice

(Change, 2010). Vesterinen, S. Marjo, S, Arja Isola

(2012) stated that nurse managers with that skill

could easily form relationships with others, read

employees feelings and responded accurately and

led successfully. Nurse managers had an important

role in leading the ward to promote patient safety

culture (Livne, Y; Raskhovits S, Peterfreund, Ilana

S., 2017). Leadership styles affected the

organizational climate and the ways how

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

184

information was given and communicated and how

question day of the day was discussed regarding the

patient safety culture (Vesterinen, S. Marjo, S, Arja

Isola, 2012).

According to Swanburg (2000) in (Setiowati, D

2010) states the head of the ward was a nurse who

had responsibility and authority in regulating and

controlling care activities in the ward. The head of

the ward as a first-line manager had a critical role in

supporting a patient safety culture with leadership

and creating a positive environment and culture for

patient safety. Fleming and Wentzell, (2008), states

that one component of the enforcement of patient

safety culture is leadership. This was in line with

Hall and Moore, (2008) stated that patient safety was

also influenced by leadership and organizational

culture, because leadership changed were strongly

influenced by the system in an organization.

Improved patient safety culture was supported by

strong leadership and systems. Candidate and

Kaya,(2014) said that nurses had a major role in

leading to improve patient safety and achieved good

quality nursing care in health care organizations.

Nurse’s leaders in patient safety programs were

compiling an initial statement about patient safety

(The Health Foundation, 2011). The contents of the

statement contained elements, about the

commitment that patient safety became important

and priority, commitment to leadership

responsibility in patient safety, use of up-to-date

knowledge and skills, and the implementation of

honest and non-blameless reports (Jonsson and

Øvretveit, 2004).

Morello R, Lowthian J, Barker A (2013) state

leaderships walk around and multi-faceted unit

based strategies ware the two strategies for which

some stronger evidence could be found to support a

positive impact. Our findings showed that the

organizational support was the most factor fluency

to the implementation of patient safety culture when

health care professionals understood to each others

roles were able to communicate and work together

effectively. The patients were more likely to receive

safe of the quality of care.

5 CONCLUSIONS

In the present research, it was found that

organizational support and the supervisors to

promoting a patient safety culture were the main

roles of the leadership of the head of the ward in

implementing a patient safety culture in the Public

Hospital Bekasi. Therefore, it was recommended

that hospitals needed to give more support to

improve the safety culture of care services and

through by supervisors to promote patient safety. To

do so, the hospitals should create an organizational

support system and committed of head nurse

supervise to promote a patient safety culture. This

would enhance the implementation of patient safety

culture by the applied nurses.

ACKNOWLEDGEMENTS

Hereby, we external gratitude to the management

and nurses of Hospitals public in Bekasi and all

colleagues in STIKes Bani Saleh for their

cooperation in this research project.

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