Ensuring patient safety through effective leadership behaviour: A literature review

Abstract

Ensuring patient safety has always been important for critical care teams. Since team and leadership skills are increasingly recognised as important for the patient’s safety, a body of literature on leadership in critical care has emerged. The purpose of this paper is to provide a systematic review on the findings of effective leadership strategies in critical care teams. We aim to contribute to a better understanding of factors influencing leadership behaviour that in turn effect team outcomes. An input–process–output model of leadership is used to systemise the findings. The results of this review clearly show that effective leaders play a pivotal role in promoting team performance and safety. Effective leadership is characterized by clear and unambiguous behaviour which is adaptable to situational demands and shared between team members. The review concludes with recommendations for future research directions.

Introduction

Teams are one of the basic functional units of organisations and are used in one way or another in all organisations including healthcare institutions. Leadership has been identified as a key variable for the functioning of teams and as one of the main reasons for the success or failure of team-based work systems implementation (e.g. Avolio et al., 1996, Day et al., 2004, Gladstein, 1984, Kozlowski et al., 1996, Stewart and Barrick, 2000, Zaccaro et al., 2001). The importance of leadership for the functioning of organisational teams is a stable finding (Yukl, 2006) and it is also becoming increasingly recognised as important for patient safety. This development is in line with other high-hazard industries such as airlines or energy and manufacturing sectors where a culture of safety is common and where the entire system of organisation and culture, including team behaviour and leadership, is designed to enhance safety behaviours (see e.g. Flin and Yule, 2004, Schimpff, 2007). Teams in critical care environments can be compared to teams in air traffic control, nuclear power generation industries or aviation because they all operate in complex environments where safety is of paramount importance and teamwork and communication are essential (Helmreich, 2000). While these industries are referred to as high reliability organizations which are “known to be complex and risky, yet safe and effective” (Leonard and Frankel, 2004, p. 15) and characterized by a commitment to safety, a culture of continuous learning and improvement, and redundancy in safety measures and personnel (Weick, 2002), there is general consensus that health care has not yet become satisfactorily safer and reliable (Frankel et al., 2006, Leape and Berwick, 2005). Therefore, the importance of safety in health care is more and more acknowledged (Frankel et al., 2006) and findings from high-reliability domains have been transferred to the medical field, for example the recognition of non-technical skills in addition to technical and clinical competencies.

For example, interactive human factors such as communication, supervision or team structure have been considered vital to assure safe and efficient work medical teams (Donchin et al., 1995, Kosnik, 2002). Conversely, breakdowns in communication, lack of coordinated care or teamwork failure can result in an unfavourable outcome for the patient (e.g. Fletcher et al., 2002, Flin et al., 2003, Gaba et al., 1987, Helmreich and Schaefer, 1994, Sexton et al., 2000). With the growing understanding of the importance of human factors alongside medical knowledge and technical skills, researchers have turned their attention to the topic of team leadership, asking questions such as how leadership behaviours influence the effectiveness of teams and describing elements that might moderate the effect of leadership on team performance and patient safety. It has been shown that failure to establish leadership for critical care teams can cause suboptimal teamwork and therefore, an increased risk to patients (e.g. Helmreich, 2000, Pollack and Koch, 2003). Moreover, positive correlations between the quality of leadership and goal achievement (Stockwell et al., 2005) and task completion (e.g. Undre et al., 2006a) have been found.

Although a growing body of literature on leadership in critical care teams exists, to our knowledge no systematic summary of this knowledge is available. As the findings differ in complexity as well as in the selected aspects on leadership behaviour and methodology, it is difficult to grasp the salient features of effective leadership in critical care teams. With this review we thereby aim to provide an important theoretical contribution to a better understanding of the skills, knowledge, and attributes leaders that critical care teams need in order to create and maintain patient safety. The focus will be on critical care teams, which we define as all teams specializing in the intensive care of patients whose conditions are life-threatening and who require comprehensive care. It is our intent that this overview of the state-of-the-art findings on leadership in critical care teams will help delineate the unique characteristics and critical functions of leadership and also uncover future research needs.

Since there appears to be considerable variation in the description of leadership in critical care teams, this paper will first provide a definition of effective leadership by bringing together the various characterisations from previous studies. This will be followed by details of the methodology used to identify the empirical articles and highlight the key features of critical care teams. As a next step, we will critically examine studies linking leadership behaviour in critical care teams working in the operating theatre to team performance, as well as studies focusing on factors mediating the relationship of leadership behaviour and performance. In so doing, we will also highlight the differences in findings and methodology across investigations. As a conceptual framework we will use the input–process–outcome (I–P–O) model. To conclude, implications for further research and practice will be suggested.