Safety of patients and their families is recognized as a priority for all healthcare organizations all over the world. However, improving patient safety and enhancing the reporting practices among healthcare organizations require effective leadership behaviors at all levels  . It was found that transformational leadership demonstrated by nurse managers had been associated with the existence of a culture of safety   . Moreover, positive leadership traits (manager support, transformational style, staff involvement in decision making, positive work environment) were associated with many outcomes as improved safety outcomes, decreased adverse events, and safety climate as well   . Moreover, transformational leadership of nurses and hospitals’ organizational culture is considered as pivotal factors in enhancing many of nurses’ and patients’ outcomes; such as retention of nurses and controlling the costs of healthcare  , promoting much more better safety outcomes for both nurses and patients  , facilitating the delivery of optimal patient care and enhancing the well-being of working nurses  , and enhancing nurses’ performance and job satisfaction  .
2. Review Methodology
Databases and Journals
The main keywords that were used for this research study are leadership, leadership behaviors, leadership styles, culture, organizational culture, reporting practices, reporting incidents, underreporting, transformational leadership, patient safety, leadership behaviors and incidents reporting, culture and incidents reporting, and safety culture. The databases that were searched include EBSCO host, MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Science Direct. Moreover, the searched literature was recent as much as possible which means the included studies were conducted in 2014 and more recent. Additionally, the obtained articles were evaluated for their significance and relevancy. Moreover, the included studies were those published in English language that means any research study was published in any language rather than English was excluded, also any abstracts without full text studies were excluded from the review. Finally, only the studies that were published between 2014 and 2019 were included in the review.
3. Results of the Searching
3.1. Leadership Behaviors and Transformational Leadership Behavior in Nursing
There are many definitions in the literature for transformational leadership, it was defined as the ability of the leader to influence and inspire others in order to achieve the goals and objectives of their institution  . Whereas Smola in (1988) defined transformational leadership as the capacity of nursing leaders to accomplish certain effective behaviors, like assessing and identifying their own needs and supporting others, possessing the ability of communication and persuasion, helping other people in organized mental manner to think clearly and logistically and to take good decisions and manage change  . Moreover, leadership was defined by Northouse (2013), as a process whereby an individual influences a group of persons in order to achieve a common goal  . Thus, the most important point in leadership is the influence in which leadership is concerned with how the leader affects followers. So, and according to Northouse (2013), without influence, leadership does not exist. Additionally, transformational leadership was defined theoretically by Sullivan (2019), as a manner of inspiration and motivation for subordinate nurses; moreover, transformational leaders foster their followers’ inborn desires to pursue higher morals, values, and humanitarian ideals  . Finally, transformational leadership was defined by Burns (1978), as one or more individuals engage with each other in such a way that leaders and followers raise one another to the highest levels of motivation and inspiration  .
There are a lot of research studies that were conducted in order to investigate the leadership styles adopted by nurse managers and its impact on staff nurses’ outcomes such as job satisfaction, and intention to stay at the work environment. One study that was conducted in Jordan in order to investigate the impact of leadership styles adopted by head nurses on job satisfaction as a comparative study between three public hospitals and three private hospitals. It was a descriptive comparative study among a convenient sample of working nurses in Amman; the study had used the multi-factor leadership questionnaire 5X tool which revealed that transformational leadership style was used by nurse managers in both settings more than transactional style and passive-avoidant leadership. Moreover, results revealed that positive relationship was found between the transformational leadership and job satisfaction (r = 0.374), whereas there was negative relationship between passive-avoidant leadership and job satisfaction (r = −0.240) where (p < 0.05)  .
Another study was conducted in Saudi Arabia in order to examine leadership styles and outcomes as perceived by 272 nurses who were working at two major public hospitals. It was descriptive cross-sectional study, and data were gathered in regards to nurses’ perception of their supervisors’ leadership styles and outcome factors, the results showed that working nurses had a perception that their bosses are more frequently using transformational and transactional than laizzes-faire leadership styles. However, there was positive relationship between transformational leadership and outcome factors (satisfaction, effectiveness, and extra efforts) (r = 0.77, p ≤ 0.001). So, it is obvious that this study is significant and highly relevant to the proposed study in which it provides supporting evidence that adopting a transformational leadership style by nurse managers will attain the best outcomes and practices among staff nurses  .
One more study was conducted by Abu-Moghli & Suleiman early in 1999 that was aimed to examine the leadership styles of nurse administrators in Jordanian hospitals, in which convenient sample consisted of nurse administrators (N = 152), and staff nurses (N = 228) were recruited for the purposes of data collection, and the results showed that nurse administrators and staff nurses were consistent in their evaluation of nurse administrators as “sometimes” transformational (p = 0.0001), transactional (p = 0.004), and “once in a while” as laissez faire (p = 0.0002). Additionally, there was an inconsistent perception of which style is significantly more dominant, nurse administrators rated themselves as predominantly transformational (p = 0.0001), whereas their staff nurses rated them as predominantly transactional (p = 0.02)  . So, it is obvious that this study is significant and relevant to the proposed study since the important issue is how the staff nurses perceive their nurse managers not how the nurse managers perceive themselves.
Additionally, in a cross-sectional study was conducted by Brewer and colleagues in (2016), which was aimed to investigate the effect of transformational leadership on nurses’ work outcomes, the study used a cross-sectional design study of nurses who had been licensed for 7.5 - 8.5 years which was part of a 10-year longitudinal panel design. The sample size was about 1037 nationally representative newly licensed nurses in USA. Data were collected from nurses through both internet-based surveys, and mailed surveys. However, it was found that transformational leadership did not have a significant influence on some nursing outcomes such as intent to stay and job satisfaction; but significantly associated with organizational commitment and honest feedback by nurses. Additionally, results showed that transformational leadership had the main role in slowing attrition and retaining nurses through creating a positive work environment that supports staff nurses  . So, it is clear that this study is highly related to the variables of interest in the proposed study in which it is crucial for nurse managers in any setting to adopt transformational leadership style in order to attain the best outcomes from their followers such as honest incidents reporting of malpractices and near-misses.
3.2. Relationship between Leadership Styles (Behaviors) and Reporting Incidents Practices
It is clear among the literature that leadership styles adopted by nurse managers are directly affecting the morality and ethical commitment among staff nurses  . In an earlier qualitative study conducted in (2015), by Kartika and colleagues which was aimed to explain transformational leadership style of a director according to seven steps of hospital patient safety in order to implement patient safety culture in Hermina Pandanaran Hospital in republic of Indonesia, the informants were head nurses and team leaders who were involved in the hospital patient safety program, and they were interviewed in depth to get their perceptions and feelings. Content analysis method was conducted to analyze the data. Obviously, it was found that transformational leadership style of a director involved nurses in the implementation of patient safety culture particularly through applying a none blaming and non-punitive culture and learning from incident culture. Additionally, it was found that the culture of reporting was not implemented properly. Moreover, there were many significant findings in this study such as that staff nurses have not been motivated optimally, steps and process of managing patient safety incident were not described directly in the setting, finally, root cause analysis RCA training in the hospital was not applied  . So, it is obvious in the previous study that the main role of nurse directors is to do more socialization on incidents reporting culture by focusing on non-blaming culture to staff nurses.
In one research study that was aimed to examine the influence of healthcare providers’ demographics (gender, age), organization characteristics, and leadership factors (organization and unit leadership support for safety) on fear of repercussions for reporting errors among nurses and physicians separately. The study adopted a cross-sectional design study on a sample size of 2319 nurse and 386 physicians from three Canadian provinces. Data were analyzed using exploratory factor analysis, multiple linear regression, and hierarchical linear regression. The results showed that clinicians’ characteristics were not significantly associated with fear of repercussions for both nurses or physicians, in addition to that leadership factors and organization demographics positively influenced nurses’ and physicians’ fear of reporting incidents, strong organization and unit leadership support for safety issues and adequate reporting had explained the most variance in fear from reporting for both nurses and physicians  . So, it is clear that the organizational characteristics such as its culture and climate and leadership factors had a pivotal role in incidents reporting practices among both nurses and physicians.
In another recent study conducted by Boamah and colleagues (2017), in order to investigate the effects of nurse managers’ transformational leadership style on job satisfaction and patient safety outcomes (nurse-assessed adverse patient outcomes which are patient falls, pressure ulcers after admission and healthcare associated infections). A random sample of 378 nurses in Ontario were surveyed, the results showed that 0.61% of the variance in patient safety outcomes were explained by effects of transformational leadership which provide support for nurse managers to adopt transformational leadership behaviors in their practice as a strategy to enhance better safety outcomes for their patients and families  .
3.3. Leadership Styles (Behaviors) and Organizational Culture
According to AbuAlRub & Nasrallah (2017), in their study aimed to investigate the impact of leadership behaviors of nurse managers as perceived by nurses and organizational culture on intention to stay among Jordanian nurses. The study was conducted in Jordanian hospitals on a convenient sample of 285 nurses who were working in three types of hospitals (public, private, and university-affiliated). The results showed that strong positive relationship exists between leadership styles (behaviors) and organization culture (r = 0.50, p = 0.001), which means that transformational leadership styles were associated with positive perceptions of organizational culture. Additionally, it was revealed that the participants perceived the leadership behaviors of their managers as transformational (the mean score was 5.4; which is slightly above the average level 5). Additionally, the participants perceived the culture of their organizations as positive (the mean of professional organizational culture scale for the whole sample was 2.59 which is slightly above the average level 2.0)  .
In a cross-sectional study which was conducted in Gaza strip in (2017), on 475 managers at 23 ministries in order to examine the influence of mediating effect of organizational culture on the relationship between transformational leadership style (behavior) and organizational learning; the results showed that organizational culture was a significant predictor of organizational learning, in addition to that organizational culture had functioned as a full mediator between transformational leadership style (behavior) and organizational learning. It is worthy here to mention that the organizational learning is considered one of the pivotal mechanisms for achieving long-term organizational success and organizational efficiency as well  .
As a summary, it is clear that leadership style adopted by leaders and organizational culture are strongly related to each other, and they can both affect the behaviors of working staff in the whole organization.
3.4. Organizational Culture and Incidents Reporting
Relationship between organizational culture and the employees’ safety behaviors is existed  . A study conducted by Mayhob & Hashim in (2017), which aimed to identify the factors that affect nurses’ attitudes toward incidents reporting. Sixty nurses who were working in one public hospital in Egypt were recruited for the purpose of data collection. The results revealed that 83% of the participants reported that absence of blame free culture is among the crucial factors that lead to under reporting of clinical incidents. Whereas 80% of the participants reported that lack of supportive culture from managers is among the crucial factors that will lead to under reporting of clinical incidents  .
Additionally, in one qualitative study that was conducted in Iran in 2015, in order to explore the organizational factors that affect the occupational accidents and its reporting, purposive sampling of 17 experts was recruited through semi-structured interviews. Findings revealed that 11 organizational factors’ subthemes were identified by the participants: management commitment, blame culture, reward system, management participation, and others. However, it was recommended by this study that enhancing the organizational culture is a must in order to increase the safety performance of working staff  .
Another quantitative study was conducted in China by Qin and colleagues in (2015), in order to analyze the behaviors of nurses in China toward reporting safety events, the main barriers to reporting, in addition to the correlations of these aspects with hospital safety culture. The participants were 1125 nurses working in 8 hospitals, where the results had shown that job satisfaction, stress recognition, safety climate, and teamwork climate greatly influenced the barriers to reporting which accounted for 28.9% of the variance. Moreover, it was concluded that more attention has to be paid to job satisfaction, and recognition of nurses’ stress in order to increase the safety culture and enhance proper incidents reporting  .
In Summary, there is a scarcity in literature that concern the impact of organizational culture on incidents reporting practices among nurses, particularly in Jordan and Arab countries; and hopefully, the emerged results from the current study will fill the gap.
3.5. Research Studies That Were Conducted in Jordan and Arab Context
One research study was conducted by AbuAlRub and colleagues in (2015), in order to explore the awareness of the incident reporting system, incidents reporting practices and barriers to adequate reporting incidents among Jordanian nurses and medical doctors in accredited and non-accredited hospitals. The study surveyed 307 nurses and 144 medical doctors at seven Jordanian hospitals, four of which were accredited and three of them were non-accredited. The results showed that nurses were more aware regarding the incident reporting system than medical doctors, however, medical doctors were less likely to report any incident on fifty percent or more of occasions. Moreover, the top three barriers to reporting incidents reported by the participants were believing that there was no point in reporting near misses, lack of feedback from managers, and their fear of disciplinary and management actions  .
Another study that was conducted in Arab gulf region particularly in Saudi Arabia in (2017) was aimed to investigate the barriers of reporting errors among nurses in a tertiary hospital. The study’s participants were 154 nurses varying between male and female. The results showed that most reported barriers of reporting errors were lack of time, overload of works assignment, and complexity of works as well  . However, the surprising result of this study was that fear of being punished and blamed by manager was not reported by participant nurses as a barrier of reporting incidents within the hospital.
Additionally, one more research study was conducted in Saudi Arabia which aimed to identify the main barriers of reporting clinical incidents among multi-cultural registered nurses and also to investigate the relationship between the nurses’ demographics and their perceptions of reporting incidents. The study had surveyed 300 nurses and the results showed that administrative response, fear of administration were respectively the main perceived barriers to reporting. Whereas, nurses with bachelor degree and non-Saudi nurses had exhibited higher perception levels of barriers in reporting incidents; however, other demographic variables such as age, experience, and gender were not significantly related to the overall barriers of reporting incidents  .
In one study which was conducted in Jordan in order to explore safety culture practices in Jordanian hospitals, the participants were 392 nurses working in 9 hospitals; public, private, and university-affiliated hospitals. The researchers had used hospital survey on patient safety culture HSOPSC tool in which it comprises 12 subscales representing different aspects of patient safety included but not limited to team-work between units and communication openness. The results showed that the highest average positive response was for teamwork within units (74.6%) whereas the lowest was for non-punitive response to error (20.0%). The most important result in that study was that nurses who are working in Jordanian hospitals were fearful of reporting errors; in where they neither freely communicate their errors nor often report errors. Moreover, the participant nurses in that study had perceived minimal support from their leaders and management for patients’ safety in their units. In addition, they reported little collaboration from outside their units. Generally, the results of that study realized that hospitals in Jordan need to adopt a culture in which patient safety and proper reporting are of great importance  .
As a summary, it is obvious that most of the research studies were conducted in order to explore the perceptions of healthcare providers about patient safety issues, and clinical incidents reporting practices as well, however, there were few studies aimed to investigate the influence of leadership behaviors and organizational culture on incidents reporting practices as perceived by Jordanian hospitals’ registered nurses.
Moreover, it seems that in Jordanian context it is not fully understood the relationship between the transformational leadership and its effects on perceptions and practices of working nurses towards clinical incidents reporting.
The researcher would like to thank the academic staff and professors at the school of Nursing in the University of Jordan for supporting this academic work.
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