The Role of Nursing Management in Patient Safety Culture: A Systematic Review

Authors

  • Kaiden budi Wahono RSUD Kanjuruhan Kabupaten Malang
  • Burhanudin Mursid Program Studi S-2 Ilmu Kesehatan Masyarakat Universitas Strada Indonesia

Keywords:

patient safety culture, nursing management, transformational leadership, staffing, communication, incident reporting, hospital

Abstract

Background: Patient safety culture is a key component of healthcare quality and remains a global priority, yet evidence on the role of nursing management is still fragmented. Objective: To identify and synthesize evidence on the role of nursing management in influencing patient safety culture in hospitals. Methods: This study used a systematic literature review (SLR) based on PRISMA 2020 guidelines. Literature was searched from PubMed, Scopus, ScienceDirect, and Google Scholar for studies published between 2015–2025. Inclusion criteria were primary research conducted in hospital settings, available in full text, and published in English or Indonesian. Data were analyzed using narrative synthesis. Results: Ten studies were included. Four key factors were identified: leadership, staffing, communication, and incident reporting. Transformational leadership was the most consistent predictor. Inadequate staffing increased adverse events, while structured communication improved safety. Reporting was hindered by fear of blame. Conclusion: Nursing management plays a crucial role in strengthening patient safety culture through integrated and non-punitive strategies.

Author Biographies

Kaiden budi Wahono, RSUD Kanjuruhan Kabupaten Malang

perawat di bangsal bedah RSUD Kanjuruhan kabupaten Malang

Burhanudin Mursid, Program Studi S-2 Ilmu Kesehatan Masyarakat Universitas Strada Indonesia

Burhanudin Mursid, Sp.B., is a general surgeon and the Head of RS Tk. III 02.06.01 dr. Bratanata, Jambi, a Class C hospital under the Indonesian Army. He is responsible for managing healthcare services and advancing quality improvement and patient safety initiatives within the hospital.

References

ALFadhalah, T., & Elamir, H. (2021). Patient safety and leadership style in the government general hospitals in Kuwait: a multi-method study. Leadership in Health Services, 35(2), 190–209. https://doi.org/10.1108/LHS-07-2021-0062

Astier-Peña, M. P., Martínez-Bianchi, V., Torijano-Casalengua, M. L., Ares-Blanco, S., Bueno-Ortiz, J.-M., & Férnandez-García, M. (2021). The Global Patient Safety Action Plan 2021–2030: identifying actions for safer primary health care. Atencion Primaria, 53(Suppl 1), 102224.

Boamah, S. A., Spence Laschinger, H. K., Wong, C., & Clarke, S. (2018). Effect of transformational leadership on job satisfaction and patient safety outcomes. Nursing Outlook, 66(2), 180–189. https://doi.org/https://doi.org/10.1016/j.outlook.2017.10.004

Churruca, K., Ellis, L. A., Pomare, C., Hogden, A., Bierbaum, M., Long, J. C., Olekalns, A., & Braithwaite, J. (2021). Dimensions of safety culture: a systematic review of quantitative, qualitative and mixed methods for assessing safety culture in hospitals. BMJ Open, 11(7), e043982. https://doi.org/10.1136/bmjopen-2020-043982

Dhamanti, I., Leggat, S., Barraclough, S., & Tjahjono, B. (2019). Patient safety incident reporting in Indonesia: an analysis using World Health Organization characteristics for successful reporting. Risk Management and Healthcare Policy, 331–338. https://doi.org/10.2147/RMHP.S222262

Echevarria, I. M., Patterson, B. J., & Krouse, A. (2017). Predictors of transformational leadership of nurse managers. Journal of Nursing Management, 25(3), 167–175. https://doi.org/https://doi.org/10.1111/jonm.12452

Etemadifar, S., Sedighi, Z., Sedehi, M., & Masoudi, R. (2021). The effect of situation, background, assessment, recommendation-based safety program on patient safety culture in intensive care unit nurses. Journal of Education and Health Promotion, 10, 422. https://doi.org/10.4103/jehp.jehp_1273_20

Hales, D. N., & Chakravorty, S. S. (2016). Creating high reliability organizations using mindfulness. Journal of Business Research, 69(8), 2873–2881. https://doi.org/https://doi.org/10.1016/j.jbusres.2015.12.056

Helena E.M., H., & Lizeth, R. (2026). Nurse leadership: Sustaining a culture of safety. Health SA Gesondheid, 27(1), 2009. https://doi.org/10.4102/hsag.v27i0.2009

Lappalainen, M., Härkänen, M., & Kvist, T. (2020). The relationship between nurse manager’s transformational leadership style and medication safety. Scandinavian Journal of Caring Sciences, 34(2), 357–369. https://doi.org/https://doi.org/10.1111/scs.12737

Merrill, K. C. (2015). Leadership Style and Patient Safety: Implications for Nurse Managers. JONA: The Journal of Nursing Administration, 45(6). https://journals.lww.com/jonajournal/fulltext/2015/06000/leadership_style_and_patient_safety__implications.8.aspx

Morales, M. J. G., Hilton, P., Hong, O., Bialous, S., Martin, M., Foley, M., & Lee, S.-J. (2025). Exploring the impact of high reliability organization implementation on patient handling injury rates: a cross-sectional study. Journal of Occupational Medicine and Toxicology, 20(1), 40. https://doi.org/10.1186/s12995-025-00487-0

Murray, J. S., Baghdadi, A., Dannenberg, W., Crews, P., & Walsh, N. D. (2024). The Role of High Reliability Organization Foundational Practices in Building a Culture of Safety. Federal Practitioner : For the Health Care Professionals of the VA, DoD, and PHS, 41(7), 214–221. https://doi.org/10.12788/fp.0486

Nantsupawat, A., Poghosyan, L., Wichaikhum, O.-A., Kunaviktikul, W., Fang, Y., Kueakomoldej, S., Thienthong, H., & Turale, S. (2022). Nurse staffing, missed care, quality of care and adverse events: A cross-sectional study. Journal of Nursing Management, 30(2), 447–454. https://doi.org/https://doi.org/10.1111/jonm.13501

Nwosu, A. D. G., Ossai, E., Ahaotu, F., Onwuasoigwe, O., Amucheazi, A., & Akhideno, I. (2022). Patient safety culture in the operating room: a cross-sectional study using the Hospital Survey on Patient Safety Culture (HSOPSC) Instrument. BMC Health Services Research, 22(1), 1445. https://link.springer.com/article/10.1186/s12913-022-08756-y

Oweidat, I., Al-Mugheed, K., Alsenany, S. A., Abdelaliem, S. M. F., & Alzoubi, M. M. (2023). Awareness of reporting practices and barriers to incident reporting among nurses. BMC Nursing, 22(1), 231. https://doi.org/10.1186/s12912-023-01376-9

Ree, E., & Wiig, S. (2020). Linking transformational leadership, patient safety culture and work engagement in home care services. Nursing Open, 7(1), 256–264. https://doi.org/https://doi.org/10.1002/nop2.386

Salsabila, N. (2023). Studi Kualitatif: Faktor-Faktor Yang Memengaruhi Pelaporan Insiden Keselamatan Pasien Pada Tenaga Kesehatan Di Puskesmas Raja Basa Indah Dan Puskesmas Kemiling Kota Bandar Lampung. Fakultas Kedokteran. https://digilib.unila.ac.id/70846/

Seljemo, C., Viksveen, P., & Ree, E. (2020). The role of transformational leadership, job demands and job resources for patient safety culture in Norwegian nursing homes: a cross-sectional study. BMC Health Services Research, 20(1), 799. https://doi.org/10.1186/s12913-020-05671-y

Sexton, J. B., Helmreich, R. L., Neilands, T. B., Rowan, K., Vella, K., Boyden, J., Roberts, P. R., & Thomas, E. J. (2006). The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Services Research, 6(1), 44. https://doi.org/10.1186/1472-6963-6-44

Vikan, M., Haugen, A. S., Bjørnnes, A. K., Valeberg, B. T., Deilkås, E. C. T., & Danielsen, S. O. (2023). The association between patient safety culture and adverse events – a scoping review. BMC Health Services Research, 23(1), 300. https://doi.org/10.1186/s12913-023-09332-8

World Health Organization. (2019). 10 facts on patient safety. WHO. https://www.who.int/news-room/photo-story/detail/10-facts-on-patient-safety

Published

2026-09-27