Intended for healthcare professionals


Nurse leadership and patient safety

BMJ 2012; 345 doi: (Published 09 August 2012) Cite this as: BMJ 2012;345:e4589
  1. Çakıl Agnew, research fellow1,
  2. Rhona Flin, professor of applied psychology 1,
  3. Jane Reid, visiting professor2
  1. 1Industrial Psychology Research Centre, School of Psychology, University of Aberdeen, Aberdeen AB24 3UB, UK
  2. 2Bournemouth University, Dorset, UK
  1. c.sarac{at}

Rounding can enhance but not ensure patient safety; better to focus on appropriate training

The UK government recently called for better nurse leadership and ward management1—for example, by calling for nurses to undertake hourly rounds—after increasing concern about the quality of patient care in the NHS. In response, the Royal College of Nursing commented that ward sisters are experienced nurses who can provide expert leadership to the team, and that they need to be able to call the shots and supervise and develop the wider workforce.2 The college’s response signals recognition that ensuring safe care is less about pronouncements from Whitehall and more to do with local ownership of local problems, underpinned by committed and effective leadership at all levels of the organisation.

The prime minister’s call to improve nursing quality through “intentional rounding”—a formal process of patient checks conducted by responsible nursing staff every one to two hours—implies that nurses would improve care merely by focusing on patients rather than on tasks. Ironically, “back rounds”—a series of nurse led actions focused on specific care needs—were cast into the wilderness by leaders in the mid-1980s, as diminishing “individualised care.” Rounds provide a means of checking that patients are comfortable and that their needs (physical and psychological) are being met, while providing an opportunity for patients and their families to identify a “visible figure of nursing authority.” Intentional rounding that focuses on patients’ needs has been shown to improve pain management and to reduce falls, dehydration, and the prevalence of pressure sores. Intentional rounding is promoted by the King’s Fund, a UK health policy think tank, as a valuable example of how ward leaders can monitor patient care and comfort, but rounds themselves are not a solution for poor quality care and cannot compensate for inadequate staffing or poor leadership.

Solutions for quality improvement are inevitably multifarious, and to assure safe, effective, and high quality experiences for patients, their implementation depends on excellent leadership. The need to instil public trust and confidence in the leadership skills of ward nurses is greater than ever given current financial challenges in the NHS and the impending report of the Francis Inquiry. Charge nurses and ward sisters must meet a variety of expectations in their roles, which include both delivery of quality clinical care and managerial duties, and this requires a high level of leadership competence. The extent to which the Department of Health, trust boards, and the public can expect nurse leaders to keep patients safe without properly preparing them to meet these demands should not be a rhetorical question, but one that prompts action for evidence gathering.

In high risk industries, leadership is recognised as an essential aspect of safety management,3 and this has resulted in the delivery of specific safety leadership programmes for all levels of managers. Interventions that target safety related monitoring, and those that reward behaviours of supervisors and motivate employees to make the workplace safe, have been shown to increase the safety behaviours of workers and reduce occupational injuries.3

Leadership at the level of the hospital ward is no different from other domains where safety is crucial. It is essentially about “influencing others to understand and agree about what needs to be done and how to do it, and the process of facilitating individual and collective efforts to accomplish shared objectives.”4 Although evidence is available on the impact of nurses’ leadership styles on organisational outcomes,5 very little research has investigated the effect of their leadership behaviours on safety related outcomes.6 Some studies of ward leadership are beginning to include patient safety outcomes, such as adverse events, patient falls, drug errors, and infection rates, but the results do not show a consistent pattern. For example, relationship oriented leadership behaviours of nurses (such as being approachable and giving feedback) were related to reduced adverse events in 164 nursing homes in the United States.7 Similarly, indirect effects of relational leadership (setting an example as a leader) of nurse managers in 46 US patient care units reduced patient falls and drug errors.8 In contrast, the level of support given to nurse managers was not related to the frequency of patient adverse events in 21 surgical and medical wards.9

The specific leadership behaviours most effective in determining a safer ward environment need to be established before initiating more leadership policies for nursing aimed at maximising patient safety. Despite the generic guidance within the NHS Leadership Framework, little empirical evidence specifies which of the leadership skills designed to increased patient safety are the most effective, either for nurses or for other clinicians.

Leadership practices are regarded as a key factor that influences nurses’ motivation and performance.10 Without training that focuses on safety how can we ensure that frontline NHS leaders do not unwittingly, and in response to economic imperatives, “drift” the system close to the boundaries of safety?11 Nurses’ leadership development requires more than political rhetoric or temporary interest to safeguard the quality of care delivered to patients in the NHS. It needs evidence based leadership training programmes designed for nurse leaders. Investing in the leadership potential of nurses should be a priority.12


Cite this as: BMJ 2012;345:e4589


  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.


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