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Abstract
Objectives The study aimed to study the association of leadership practices and patient safety culture in a dental hospital.
Design Hospital-based, cross-sectional study
Setting Riphah Dental Hospital (RDH), Islamabad, Pakistan.
Participants All dentists working at RDH were invited to participate.
Main outcome measures A questionnaire comprised of the Transformational Leadership Scale (TLS) and the Dental adapted version of the Medical Office Survey of Patient Safety Culture (DMOSOPS) was distributed among the participants. The response rates for each dimension were calculated. The positive responses were added to calculate scores for each of the patient safety and leadership dimensions and the Total Leadership Score (TLS) and total patient safety score (TPSS). Correlational analysis is performed to assess any associations.
Results A total of 104 dentists participated in the study. A high positive response was observed on three of the leadership dimensions: inspirational communication (85.25%), intellectual stimulation (86%), and supportive leadership (75.17%). A low positive response was found on the following items: ‘acknowledges improvement in my quality of work’ (19%) and ‘has a clear sense of where he/she wants our unit to be in 5 years’ (35.64%). The reported positive responses in the patient safety dimensions were high on three of the patient safety dimensions: organisational learning (78.41%), teamwork (82.91%), and patient care tracking/follow-up (77.05%); and low on work pressure and pace (32.02%). A moderately positive correlation was found between TLS and TPSS (r=0.455, p<0.001).
Conclusions Leadership was found to be associated with patient safety culture in a dental hospital. Leadership training programmes should be incorporated during dental training to prepare future leaders who can inspire a positive patient safety culture.
- Patient safety
- Safety culture
- Leadership
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Organisational environment and leadership influence staff behaviours and attitudes towards patient safety practices in nursing studies.
WHAT THIS STUDY ADDS
The role of leadership in affecting patient safety practices in a dental hospital is explored in this study.
HOW THIS MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY
The findings may be used to inform policy to train leadership in dental settings.
Introduction
Despite significant progress in the area of ‘patient safety’ over the last 15–20 years, it is still a major public health problem around the world.1 Medical errors are responsible for 9.5% of all mortalities in the USA, surpassed only by cancer and cardiovascular disease.2 More than 237 million medication-related errors occur every year in England alone. These errors result in over 1700 deaths every year.3 4
The modern concept of providing quality healthcare makes patient safety an essential pillar of healthcare practice.5 Safer primary care is a fundamental part of the United Nation’s Sustainable Development Goals.6
A WHO report suggests that developing countries lack the facilities and infrastructure required to ensure patient safety protocols are in place.7 Subsequently, the expected rate of adverse events secondary to medical errors would be even higher than that reported for developed countries. Such an estimate raises major concerns for public health safety.
Dentistry is an important part of primary healthcare. When the topic of patient safety is talked about, dentistry is usually not an area of concern. It has become more of a myth among the healthcare fraternity that dental errors do not cause serious harm. As a result, no specific tool has been designed to measure patient safety incidents in dentistry.8 In real-world dental practice, severe incidents do occur in dentistry. Using dentistry-related keywords, Thusu et al searched the National Patient Safety Agency database for any patient safety incidents (PSI). A total of over 2000 PSIs were identified, out of which 5.5% (n=111) were medical emergency incidents.9 Bailey et al10 reported that patient safety systems in dentistry are still not adequately tested.10
Medical errors are not performed by healthcare professionals intentionally. It is the complexity of healthcare systems that impacts the performance of professionals and thus, results in errors.11 Evidence suggests that both human and system factors are responsible for PSIs. The five most commonly reported risk factors for patient safety are active failures, individual factors, communication systems, equipment and supplies, and management of staff and staffing levels.12 It is interesting to note that all factors are in some manner integrally related to the organisational environment.
Several factors impact the performance of individuals in organisations, thus leading to motivation to perform better.13 Similarly, in healthcare, a highly motivated workforce is imperative to achieving better outcomes. The characteristics of an organisation, along with the building of social relationships contribute to a workplace environment.14
The AHRQ’s (Agency for Healthcare Research and Quality) ‘Integrative model of healthcare working conditions on organisational climate and safety’ model suggests that leadership styles impact the characteristics of an organisational climate as well as the management design and workplace culture and environment. Patient care and patient safety outcomes are also affected due to these factors. The satisfaction of healthcare professionals and patient-related outcomes are impacted as well.15 This model primarily describes the impact of two primary constructs—leadership and organisational climate—on patient and healthcare professionals’ outcomes. Using this model, we have an understanding that healthcare leadership is a significant driving force in contributing towards patient safety in a healthcare working environment. Leadership is a factor that determines the workplace environment. If the leadership does not instil patient safety as a central factor in the hospital environment, employees will not rate safety practice as one of the important factors. Leaders’ behaviours impact the safety culture at the workplace, thereby affecting indicators of patient safety.16 Furthermore, leadership may affect the employees’ performance in two ways. First, leaders have an indirect effect through their choice of management style. Second, leaders have a direct impact on how employees perform by leading by example and acknowledging their performance.17 18 Thus, leadership style in healthcare is of paramount importance in the safety realisation of healthcare workers.19
There is a paucity of literature exploring the impact of leadership on patient safety in a dental work environment. This study aimed to assess the association of leadership style and patient safety practices in a dental work environment.
Methods
Setting
The study was conducted at Riphah Dental Hospital (RDH), Islamabad. RDH is the largest dental hospital in Islamabad with over 100 dental units and about 120 dentists working in the hospital. Since, it is a teaching hospital, 150 dental students perform their clinical work in the hospital as well.
Ethical considerations
The willingness of the participants to fill out the questionnaires was considered as implied consent. The names of the participants were not recorded on the questionnaire sheets. A unique code number was allotted to each of the participants. The code numbers were written on each of the questionnaires.
Study cohort
A printed copy of the questionnaire was handed out to each participant and then, filled copies were collected at a mutually agreed time. All dentists working at RDH were invited to participate in the study.
Study instrument
Leadership style was assessed from the Transformational Leadership Scale (TLS) derived from the work of House and Podsakoff.20 The TLS is a valid and reliable 15-item questionnaire with five subdimensions (vision, inspirational communication, intellectual stimulation, supportive leadership, and personal recognition). The items on this scale have been tested for validity and reliability. Each dimension has three items. Each item has five Likert scale responses ranging from 1 (strongly disagree) to 5 (strongly agree). The dental-adapted version of the Medical Office Survey on Patient Safety Culture (MOSOPS) was used to assess the prevalence of PS practices in the dental hospital.21 The dental-adapted version of the MOSOPS has 44 items under 10 main composite sections and two overall evaluation/supplementary sections. For all of the 44 items, the participants were asked to give their responses on a five-item Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). In the first supplementary section, the participants are presented with nine different scenarios/situations related to ‘Patient Safety and Quality’. They are asked about their estimate of how frequently such an event has occurred in the past 12 months. In the second supplementary section, the participants were asked about information exchange with other settings. They were asked how frequently problems in such exchange had occurred in the past 12 months. In both these supplementary sections, the respondents were asked to report their perception of the frequency of each adverse event on a five-item Likert scale as follows: ‘Daily’, ‘Weekly’, ‘Monthly’, ‘Several Times in the Past 12 Months’, and ‘Never in the Past 12 Months’.
Statistical analysis
All collected data were entered and analysed using the Statistical Package for the Social Sciences (SPSS) V.26.0. For data analysis purposes, the responses for both instruments were dichotomised into ‘positive’ and ‘negative’ responses. Since the instruments included both positive and negative statements, the categorisation was done differently for both types of statements. For positive statements, the ‘Strongly Agree’, ‘Agree’, and ‘Neutral’ responses were categorised as ‘positive responses’, while ‘Disagree’ and ‘Strongly Disagree’ were placed under the ‘negative responses’ category. The negative statements were reverse-coded. For the negative statements, ‘Disagree’ and ‘Strongly Disagree’ were marked as ‘positive responses’, while ‘Strongly Agree’, ‘Agree’, and ‘Neutral’ were marked as ‘negative responses’. Positive response rate was calculated for each item by calculating the frequency and percentage of positive responses. The frequencies and percentages were described for each item and the cumulative categories as well. The responses for ‘Patient Safety and Quality Issues’ and ‘Information Exchange with Other Settings’ were marked in terms of frequency of occurrence. If an event was perceived as occurring ‘Daily’, ‘Weekly’, or ‘Monthly’, it was categorised as a ‘negative response’. However, if the event occurred ‘Several Times in the Past 12 Months’ or ‘Never in the Last 12 Months’, it was categorised as a ‘positive response’.
For further analysis, each positive response was given a score of ‘1’. The total positive responses were added and mean positive responses were calculated for each dimension of Leadership and Patient Safety. The scores of all items were added to calculate the ‘Total Leadership Score’ (TLS) and ‘Total Patient Safety Score’ (TPSS) Mean and SD were described for each of the dimension scores, TLS and TPS. Correlational analysis was then conducted to assess the association between each of the leadership dimensions and TLS with the Patient Safety dimension scores and TPSS. Pearson’s correlation coefficient was described for each correlation.
Results
Out of the 120 dentists working at RDH, 10 were on leave. Six participants refused to participate and a final sample of 104 dentists (response rate=86.7%) participated in the study. Out of these, the maximum of dentists were house officer residents (n=60, 57.7%), followed by 25 (24%) postgraduate residents, seven (6.7%) demonstrators, and 12 (11.6%) consultants.
Among the five leadership dimensions assessed, the lowest positive response was observed for ‘Personal Recognition’ (57.14%), with a significantly low response recorded for the ‘acknowledges improvement in my quality of work’ item (19%). This was followed by the ‘vision’ dimension (61.89%). An interestingly low positive response was observed for the ‘has a clear sense of where he/she wants our unit to be in 5 years’ item (35.64%). A greater than 80% was observed for all the items in the ‘inspirational communication’ and ‘intellectual stimulation’ dimensions. A response of between 70% and 80% was recorded for the ‘supportive leadership’ Dimension (table 1).
Positive responses for the leadership dimensions
For patient safety, three of the 10 categories reported a positive response rate of less than 50%. The ‘teamwork’ category had the highest reported positive response rate. The lowest rate was observed for ‘work pressure and pace’ (32%), with the lowest responses recorded for the ‘In this office, we often feel rushed when taking care of patients’ (19.23%) and ‘we have too many patients for the number of providers in this office’ (21.57%) items as shown in online supplemental table 2.
Supplemental material
The mean scores for leadership and patient safety dimensions are shown in table 2. Correlational analysis was conducted for the mean scores for PS and leadership (table 3). All of the leadership category scores except ‘vision’ were found to have a significant correlation with the Total Patient Safety Score. ‘Inspirational communication’, ‘intellectual stimulation’, and ‘total leadership’ scores had a weak or moderate correlation with nine of the patient safety categories (table 3). The overall leadership was found to have a positively moderate correlation with overall patient safety (Pearson’s correlation coefficient=0.455; p<0.001). The abbreviations used in table 3 are shown in table 4.
Mean scores for all leadership and patient safety dimensions
Pearson’s correlation coefficient values between the leadership scores and patient safety scores
Full terms for abbreviations used for terms used in data tables
Discussion
In the current setting (RDH), ‘intellectual stimulation’ was found to have the highest positive response (86%), which shows that the leadership at RDH inspired critical thinking and ‘out of box’ thinking in the hospital environment. Moreover, ‘inspirational communication’ also had a high response rate (85.25%), suggesting that participants highly valued their association with RDH and accepted the range of professional growth opportunities available to them. Boamah et al22 reported inspirational motivation to be the strongest factor contributing to nurse and patient outcomes.22
‘Supportive leadership’ was also observed to have a high response suggesting that the leadership valued and entertained the feelings, interests, and needs of its employees. ‘Personal recognition’ generally had good responses, except for ‘acknowledges improvement in my quality of work’ with a low positive response rate of only 19%. This indicated that despite facilitating the needs of the staff, encouraging, and appreciating the efforts of employees was not a regular practice at RDH. Workplace recognition in dentistry is identified as an important factor for stress management.23 Lower stress levels lead to better improved workplace performance and thus, leads to better patient outcomes.24
Finally, while evaluating the ‘vision’ dimension, ‘has a clear sense of where he/she wants our unit to be in 5 years’ had a positive response of only 35.64%. Also, a response rate of 57.28% was reported for ‘has no idea where the organisation is going’. This indicates a deficiency or lack of clarity of vision of leadership. The vision may be defined on paper but the direction of how to achieve the vision and its related goals appears to be unclear. In dentistry, people used to be placed into leadership positions because of the responsibilities that came with their job requirements. A leadership position was not a conscious or intentional choice for dentists until recently. In the last couple of decades, dental leadership has been recognised as an independent identity. Dental leaders have the vision to inspire their team members to work towards collective goals. Busby further describes the concept of this vision in a dental setup in his definition of dental leadership as ‘the ability to continuously define a future practice vision which inspires you and your dental team towards success’.25 It is this vision that helps the dental team to work towards attainable goals. However, the definition of success can vary, and it is important to understand what success means in a particular setup. Among other outcomes, improved patient outcomes and patient safety must be included in the vision and success criteria of any dental setup.
Busby has described three different dimensions of leadership as being the ‘pillars of leadership’: vision, motivation, and delivering the key outcomes. He further goes on to describe leadership in the dental context as ‘the ability to continuously define a future practice vision which inspires you and your dental team towards success’.25 Nalliah presented an interesting perspective on the leadership characteristics of dentists. He argued that the professional characteristics that define a good dentist and in contrast to what is required for being a good leader. For instance, he poses the point that a good dental practitioner needs to be autonomous and self-reliant in his practice while paying meticulous attention to finding details.26 A good leader, on the other hand, exhibits interdependence, is creative, and is focused on the ‘bigger picture’. That need not be the case in practical scenarios. Future leaders are expected to be multifaceted, possessing a range of traits, instead of a set of defined characteristics.27 A dentist may be focused on the fine details of the contour of restoration while treating a patient, but when he needs to procure equipment for the department, he can exercise delegation and trust in colleagues who have been trained in the process of procuring dental equipment. Also, when a dentist needs to develop a multidisciplinary plan for managing patients, he would trust the opinion of other professionals who are experts in their disciplines. As shown in the present study, participants responded well to the items in the ‘supportive leadership’ subsection, illustrating the point that dentists are comfortable working in an environment where their opinions and needs are valued.
faceted, possessing a range of traits, instead of a set of defined characteristics.27 A dentist may be focused on the fine details of the contour of restoration while treating a patient, but when he needs to procure equipment for the department, he can exercise delegation and trust in colleagues who have been trained in the process of procuring dental equipment. Also, when a dentist needs to develop a multi-disciplinary plan for managing patients, he would trust the opinion of other professionals who are experts in their disciplines. As shown in the present study, participants responded well to the items in the ‘supportive leadership’ subsection, illustrating the point that dentists are comfortable working in an environment where their opinions and needs are valued.
Recent literature has identified a different type of leadership referred to as ethical leadership (EL).19 Based on ethical values, EL is driven by positive psychology, whereby a leader works towards creating a safe working environment for the employees, which in turn leads to improved patient outcomes.28
Interesting findings were reported for the patient safety section. The ‘overall perception of patient safety and quality’ dimension showed alarming findings. A trend of commonly occurring mistakes and a consequent urgency to complete a greater number of tasks rather than provide quality care was observed. Yansane et al also assessed the patient safety culture in different dental settings using the dental-adapted version of the MOSOPS. They reported that the lowest scores (49%) were reported for the ‘work pressure and pace’ dimension in dental institutions, indicating a higher workload and increased pressure on the dentists.21
However, a positive trend of adapting office practices to rectify apparent errors was reported with a high positive rate (78.41%). Additionally, a highly positive teamwork spirit was found (82.91%), suggesting that the coherence of the dental team was inspired by good leadership practice. ‘Staff in this office are asked to do tasks they haven’t been trained to do’ had a low positive response of 23.30%. This indicates that although staff training was a regular training feature, the appropriate training was not being conducted.
A high patient load for effective management (23%) and the urgency to complete procedures quickly (19.23%) was perceived as a significant issue impacting patient safety practices. Moreover, a lack of organisation in the departments (41%) was perceived to negatively impact the workflow (32.65%). Although ‘Leadership Support’ was reported to have a high response as a leadership dimension, it was seen as a negatively perceived category from a patient safety perspective. The leadership was reported to not spending an adequate number of resources for improving quality care (positive response=15%); along with overlooking mistakes related to patient care (positive response=31.68%). Management decisions were perceived to be made based on the hospital’s interests rather than those of the patients (positive response=40.35%). This also suggests that the organisation’s interests were not perceived to be aligned with that of the patients in general. The responsibility of ensuring that systems and solutions that focus on patient experience improvement are in place lies on the dental leadership. Punishing the staff for minor mistakes is not considered a practical solution. Instead, efforts to promote a culture that facilitates patient safety practices should be promoted.21 29
A highly interesting finding was that staff highly felt that their errors were held against them (positive response=17.2%). They were also afraid to ask questions (41.67%) and felt that it was difficult to voice disagreement at the workplace (33.33%). An authoritative or dictatorial leadership style leads to poor performance of healthcare professionals and thereby has a negative impact on patient outcomes.30 Such a dictatorial style of leadership is highly discouraged in modern medical workplaces.31
Patients’ follow-up practices were well perceived by the staff at the RDH (positive response=77.05%). Also, the staff generally agreed that the hospital provided evidence-based, cost-effective, and individualised patient care without discriminating against any patient (positive response=85.03%). The participants also perceived that such processes had been put into practice that helped identify patient-related problems (87.63%). Due to the high patient load, getting a timely appointment (46.94%), problems with finding patient records (48.48%), not uploading medication lists (42.57%) and dental equipment failing and needing repair (20.39%) were reported to have low positive responses. This indicates a deficiency in the management practice to handle a high patient volume. Patient flow practices need to be improved with significant barriers identified and removed. Interestingly, few participants believed that the challenging and changing circumstances were opportunities (positive response=17.65%). This suggests that staff need to be trained to appreciate workplace challenges as learning opportunities for professional growth and development. Staff training is propagated as a significant step in preventing patient safety-related incidents.32
Finally, the staff perceived that information exchange with different medical setups frequently faced some issues (positive response=28.88%). Since all the identified places in this category had a low positive response, this indicates problems in the infrastructure to transport information and/or samples to other places. As the transfer of items/information is of health-related significance, these gaps in the process must be identified and rectified accordingly. Interestingly, Yansane et al reported that dentists reported a higher positive response in the ‘information exchange with other settings’ as compared with their medical counterparts.21 A simple explanation for this is because of a much lesser exchange of information with other settings in dentistry as compared with medicine. The lower response rate of the current study is hard to explain. Since over 70% of the respondents thought that the frequency of problems in this information exchange is quite frequent, there must be some flaw in the processes of exchange in this particular dental setting. Moreover, the non-response rate for these items was quite high as well. It is quite possible that the participants may not have answered these questions because they did not want to report their opinions on this matter. Not reporting adverse events adversely impacts patient safety. Effective reporting can only be brought into practice by supporting a safety culture where healthcare professionals are encouraged and empowered to report adverse events.33
Overall, leadership was found to be moderately correlated with patient safety (Pearson’s correlation coefficient=0.455). Ree and Wig studied the association between transformational leadership and patient safety culture among 139 healthcare professionals in-home care services. A multiple regression analysis found transformational leadership to be the strongest predictor for a positive safety culture (β=0.30).34 Effective leadership can have a positive influence on multiple factors ranging from positive teamwork to situational awareness. These factors contribute to patient safety and quality of care.16
‘Vision’ had either no or very weak correlations with the different patient safety dimensions. This suggests that although having a future vision is important, it does not significantly impact patient safety culture.
Recommendations
The Collective Leadership for Safety Cultures (Co-Lead) programme was initially designed for multidisciplinary teams.35 The premise of this programme lies within the concept of collective leadership to promote effective teamwork practices and facilitate a positive patient safety culture. This underlying concept for collective leadership is that leadership is not merely the responsibility of a single individual, rather it is a team responsibility. Since the practice of dentistry involves a collaborative team effort of different specialties, the Co-Lead programme could turn out to be effective in a dental hospital as well.
Effective and evidence-based methods for training leaders in dentistry should be employed by oral healthcare setups to prepare transformational leaders who can inspire their staff to effectively work and create a work environment where patient safety outcomes are incorporated within the very culture of the workplace. Furthermore, future studies should include dental auxiliaries (including dental nurses, technicians, and hygienists), administrative staff, and other supporting staff in future studies.
Limitations
A primary limitation of this study was its cross-sectional study design. Future studies should focus on a longitudinal design that can monitor how leadership styles impact patient safety practices over some time. Moreover, the instruments used for this study relied on a self-reported methodology. Self-reported results are open to bias and results that differ from the ground reality may well be observed in such studies. Furthermore, this was only a single-centre study.36 Data from multiple hospitals can give a larger overview of the situation providing relatively more generalisable results.37 Finally, only dentists were included in this study. Including dental nurses, dental technicians, administrative staff, and other supporting staff in the hospital would give a more holistic representation of the workplace environment.
Conclusion
Although all the leadership dimensions did not have a significant association with patient safety culture, the overall association found suggests the presence of a positive relationship between patient safety and leadership in dental settings. Since this association has not been studied in the dental specialty before, this is a novel study and will provide evidence for future research in this area. Moreover, the growing concern regarding patient safety-related adverse events in dentistry warrants that factors contributing to these issues should be addressed. It is suggested that leadership training programmes focusing on effective team building and effective communication should be incorporated for dentists at various levels.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approvals were taken from the Ethical Review Committee of Chester University and the Institutional Review Committee of RDH.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors All authors made significant contributions to the article. HS, guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.