Abstract
Patient safety remains a critical priority within healthcare systems globally, with incident reporting serving as a fundamental mechanism for identifying risks and facilitating organisational learning. This dissertation synthesises contemporary evidence examining the relationship between leadership behaviours and incident reporting practices within hospital settings. Through systematic literature synthesis, the study identifies four key leadership behaviour domains that most strongly predict reporting frequency and learning from safety events: transformational leadership approaches, coaching-oriented behaviours, non-punitive responses to error, and participative relational styles. The evidence demonstrates that leaders who provide intellectual stimulation, offer constructive feedback, maintain blame-free environments, and build trust-based relationships with staff consistently achieve higher incident reporting rates and more effective dissemination of lessons learned. These findings hold significant implications for healthcare leadership development, suggesting that targeted interventions focusing on these specific behavioural competencies may substantially enhance patient safety culture. The synthesis concludes that cultivating these leadership behaviours represents a modifiable organisational factor with considerable potential to strengthen safety reporting systems and ultimately improve patient outcomes across diverse hospital settings.
Introduction
Patient safety constitutes a fundamental pillar of quality healthcare delivery, with the World Health Organization estimating that adverse events affect approximately one in ten hospitalised patients worldwide (World Health Organization, 2021). Incident reporting systems represent a cornerstone mechanism through which healthcare organisations identify, analyse, and learn from safety events, near-misses, and errors. However, substantial evidence indicates that incident reporting remains significantly underutilised, with studies suggesting that only a fraction of safety events are formally documented (Sari et al., 2007). This reporting gap represents a critical barrier to organisational learning and continuous improvement in patient safety.
The relationship between organisational leadership and safety culture has received increasing scholarly attention over recent decades. Leadership behaviours shape the psychological safety of work environments, influence employee willingness to speak up about concerns, and determine how organisations respond to and learn from safety events (Edmondson, 2019). Within healthcare specifically, the hierarchical nature of hospital environments and the high-stakes consequences of errors create particular challenges for establishing cultures where staff feel empowered to report incidents without fear of retribution.
Understanding which specific leadership behaviours most effectively promote incident reporting and organisational learning carries substantial practical significance. Healthcare organisations invest considerable resources in leadership development programmes, yet evidence-based guidance regarding which behavioural competencies yield the greatest safety culture improvements remains fragmented across disparate studies. Synthesising this evidence provides actionable insights for healthcare administrators, policymakers, and leadership educators seeking to enhance patient safety through targeted behavioural interventions.
This matter holds particular academic importance given the theoretical intersection of leadership studies, organisational behaviour, and patient safety science. The mechanisms through which leadership influences reporting behaviour involve complex interactions between individual psychology, team dynamics, and organisational structures. Examining these relationships advances scholarly understanding of how safety cultures develop and sustain themselves within complex adaptive systems such as hospitals.
From a societal perspective, improving incident reporting directly impacts patient welfare. Enhanced reporting enables earlier detection of systemic vulnerabilities, facilitates timely corrective actions, and generates evidence for system-wide improvements. Given the considerable human and economic costs of preventable healthcare harm, identifying leadership approaches that strengthen reporting cultures represents a matter of significant public health importance.
Aim and objectives
The primary aim of this dissertation is to identify and critically analyse the leadership behaviours that most strongly predict incident reporting and organisational learning from safety events within hospital settings.
To achieve this aim, the following objectives guide the investigation:
1. To examine the evidence regarding transformational leadership approaches and their relationship with incident reporting practices and safety culture outcomes.
2. To evaluate the role of coaching-oriented leadership behaviours, including feedback provision and reflective guidance, in promoting incident reporting intention and culture.
3. To analyse how non-punitive, just culture leadership approaches influence staff willingness to report safety events and near-misses.
4. To investigate the contribution of participative and relational leadership styles to building trust and enhancing reporting behaviours.
5. To synthesise findings across these domains to develop an integrated understanding of high-impact leadership behaviours for patient safety improvement.
Methodology
This dissertation employs a literature synthesis methodology, systematically examining and integrating findings from peer-reviewed empirical studies investigating leadership behaviours and incident reporting in healthcare settings. This approach proves appropriate given the study’s aim of consolidating evidence across multiple research contexts to identify consistent patterns and relationships.
The synthesis draws upon quantitative, qualitative, and mixed-methods studies published in peer-reviewed journals, prioritising research conducted within hospital environments. Studies were identified through database searches and systematic review articles, with selection criteria emphasising methodological rigour, relevance to the research objectives, and publication in reputable academic outlets.
The analytical approach involves thematic organisation of evidence according to the leadership behaviour domains identified in the literature. For each domain, the synthesis examines the strength and consistency of associations with incident reporting outcomes, considers potential moderating factors, and evaluates the quality of supporting evidence. Where studies employed intervention designs, particular attention is given to the causal mechanisms proposed and observed.
Critical appraisal of included studies considers factors including sample characteristics, measurement validity, potential confounding variables, and generalisability of findings. The synthesis acknowledges methodological limitations across the evidence base, including the predominance of cross-sectional designs in some domains, potential social desirability bias in self-reported measures, and variations in outcome definitions across studies.
The literature synthesis methodology enables integration of diverse study designs and geographical contexts, facilitating identification of robust patterns whilst acknowledging contextual variations. This approach aligns with contemporary guidance on evidence synthesis for healthcare improvement, recognising that complex interventions such as leadership development require nuanced understanding of mechanisms and contexts rather than simple effect size estimation.
Literature review
The significance of incident reporting in healthcare safety
Incident reporting systems serve multiple functions within healthcare organisations, including surveillance of safety hazards, identification of system vulnerabilities, and generation of learning opportunities. Effective reporting systems enable organisations to detect patterns in safety events, implement targeted interventions, and track improvement over time. The National Health Service in England, for example, processes millions of patient safety incident reports annually through the National Reporting and Learning System, using this data to issue safety alerts and guidance (NHS England, 2023).
Despite the recognised importance of incident reporting, substantial evidence documents persistent underreporting across healthcare settings. Studies estimate that fewer than 10% of adverse events are formally reported through official channels (Sari et al., 2007). Barriers to reporting include time constraints, uncertainty about what constitutes a reportable event, scepticism about whether reporting leads to meaningful action, and fear of punitive consequences. Understanding and addressing these barriers represents a priority for patient safety improvement efforts.
Transformational leadership and patient safety culture
Transformational leadership theory, originally articulated by Burns and subsequently developed by Bass, describes leadership characterised by intellectual stimulation, inspirational motivation, individualised consideration, and idealised influence. Leaders exhibiting these behaviours inspire followers to transcend self-interest for collective goals, stimulate creative problem-solving, and model desired values and behaviours. The application of transformational leadership theory to healthcare safety has generated substantial empirical attention.
Tutiany et al. (2019) conducted an intervention study implementing a patient safety culture-based leadership model incorporating transformational components. The study found that intellectual stimulation, idealised influence, and leaders’ self-confidence significantly increased incident reporting frequency and learning from safety events. These findings suggest that leaders who challenge existing practices, model commitment to safety, and demonstrate confidence in safety improvement efforts create conditions conducive to reporting.
ALFadhalah and Elamir (2021) examined leadership styles across government general hospitals in Kuwait, employing multi-method approaches to investigate associations with patient safety culture. Their findings confirmed that transformational leadership was associated with better patient safety culture and higher reporting practices. Similarly, Indriani, Kusumapradja and Anindita (2022) found positive relationships between transformational leadership and safety culture compliance, including reporting behaviours, in Indonesian hospital settings.
Ginsburg et al. (2010) provided particularly compelling evidence regarding formal leadership for safety at the hospital level. Their study demonstrated that such leadership predicts learning from minor, moderate, and near-miss events, as well as dissemination of lessons learned. This research highlights that leadership behaviours influence not merely reporting volume but the subsequent organisational processes that translate reports into safety improvements.
Coaching-oriented leadership behaviours
Leader coaching behaviour encompasses providing feedback, offering guidance, and encouraging reflective practice among subordinates. Within healthcare contexts, coaching approaches align with contemporary understanding of professional development and adult learning, emphasising experiential learning and practice-based reflection. The relationship between coaching behaviours and incident reporting has emerged as a significant focus within the literature.
Chegini et al. (2020) examined the impact of patient safety culture and leader coaching behaviour on intention to report errors among nurses in Iranian hospitals. Their cross-sectional survey identified leader coaching behaviour as strongly associated with intention to report errors, functioning as an independent predictor of reporting intention even when controlling for other safety culture dimensions. These findings highlight that specific supportive behaviours from direct supervisors meaningfully influence individual reporting decisions.
El-Sayed et al. (2025) extended this evidence through their study of critical care nurses, finding leader coaching behaviour to be the strongest predictor of a positive incident reporting culture. Their analysis demonstrated particularly strong associations with communication about safety, learning from errors, and provision of feedback following reports. This research suggests that coaching behaviours operate through multiple pathways, enhancing both willingness to report and organisational capacity to utilise reported information productively.
The coaching literature emphasises that effective coaching involves not merely corrective feedback but supportive dialogue that promotes psychological safety and professional growth. Leaders who engage in coaching create relationships characterised by trust, openness, and shared commitment to improvement, conditions that reduce barriers to reporting and enhance perceived value of contributing to safety systems.
Non-punitive responses and just culture
The concept of just culture represents a foundational principle in contemporary patient safety practice. Originating from high-reliability industries such as aviation, just culture approaches distinguish between blameworthy actions resulting from reckless behaviour and honest errors arising from system vulnerabilities. This distinction enables organisations to respond proportionately to different types of events whilst maintaining psychological safety for staff to report concerns.
Perceived non-punitive response to error emerges consistently as a critical determinant of reporting behaviour. Chegini et al. (2020) identified blame-free leadership as strongly influential upon willingness to report, with staff perceptions of likely responses substantially shaping reporting decisions. Desty (2025) reinforced these findings through systematic literature review, concluding that non-punitive organisational responses represent a key safety culture element linked to higher reporting.
Indriani, Kusumapradja and Anindita (2022) provided particularly detailed analysis of blame culture effects, demonstrating that high blame culture from leaders reduces nurses’ reporting behaviours. Conversely, their study found that reducing blame whilst increasing organisational support improves reporting rates. This bidirectional relationship suggests that interventions addressing punitive cultures may yield substantial reporting improvements.
Yusuf and Irwan (2021) synthesised evidence regarding nurse leadership styles and reporting culture through systematic review, identifying open communication, feedback on errors, and management support as key elements linked to higher reporting. Their analysis emphasised that leaders establish cultural norms regarding acceptable responses to error, with these norms powerfully shaping staff behaviour regardless of formal policies.
Relational and participative leadership approaches
Leader-member exchange theory examines the quality of dyadic relationships between leaders and individual followers, recognising that leaders develop differentiated relationships characterised by varying levels of trust, respect, and mutual obligation. High-quality leader-member exchange relationships feature greater support, communication, and developmental opportunities.
Jungbauer et al. (2018) applied leader-member exchange theory to incident reporting, proposing a dual process model explaining how relationship quality influences reporting intention. Their research demonstrated that high-quality leader-member exchange builds reporting-specific trust, which in turn increases intention to report incidents. This mechanism suggests that relational investments between leaders and staff yield specific safety culture benefits beyond general job satisfaction effects.
Al-Oweidat et al. (2023) examined nurses’ perceptions of leadership behaviours and organisational culture influences on patient safety incident reporting practices. Their findings emphasised the importance of supportive leadership behaviours and trust-building in creating conditions conducive to reporting. Staff who perceived their leaders as trustworthy and supportive demonstrated greater willingness to engage with reporting systems.
Participative leadership styles, characterised by involving subordinates in decision-making processes, have also demonstrated associations with safety culture outcomes. Hernawati, Zulfendri and Nasution (2021) found participative leadership styles associated with higher nurse compliance with patient safety culture expectations, including reporting behaviours. Participative approaches may enhance reporting through multiple mechanisms, including increased ownership of safety systems, greater understanding of safety priorities, and strengthened identification with organisational safety goals.
Integration across leadership domains
The evidence across these four leadership domains reveals consistent themes whilst highlighting distinct mechanisms. Transformational leadership operates primarily at the cultural level, establishing organisational values and demonstrating commitment to safety through visible prioritisation. Coaching behaviours function at the interpersonal level, building individual capacity and confidence to engage with reporting systems. Non-punitive approaches address psychological barriers to reporting, reducing fear-based inhibition. Relational and participative styles build trust foundations that enable authentic engagement with safety improvement efforts.
These mechanisms appear complementary rather than competing, suggesting that comprehensive leadership approaches incorporating multiple behaviour domains may yield synergistic effects. Leaders who combine inspirational vision with supportive interpersonal behaviours, maintain consistent non-blaming responses, and involve staff in safety-related decisions create multifaceted conditions supporting robust reporting cultures.
Discussion
The synthesised evidence presents compelling support for the proposition that specific leadership behaviours meaningfully predict incident reporting and organisational learning in hospital settings. This discussion critically examines the implications of these findings, considers their alignment with the stated objectives, and explores practical and theoretical significance.
Regarding the first objective concerning transformational leadership, the evidence consistently demonstrates associations between transformational behaviours and enhanced safety culture outcomes. The intervention study by Tutiany et al. (2019) provides particularly valuable causal evidence, demonstrating that implementing transformational leadership approaches yields measurable improvements in reporting frequency. This finding carries substantial practical significance, suggesting that leadership development programmes emphasising intellectual stimulation, idealised influence, and confidence-building may generate tangible safety culture improvements.
However, critical appraisal necessitates acknowledging limitations in this evidence base. Cross-sectional studies, whilst demonstrating associations, cannot definitively establish causal direction. Staff who already work in positive safety cultures may perceive their leaders more favourably, creating potential for reverse causation or confounding by unmeasured organisational factors. The intervention study addresses this limitation partially, yet single-site studies require replication across diverse contexts.
The second objective regarding coaching behaviours receives strong support from the evidence, with both Chegini et al. (2020) and El-Sayed et al. (2025) identifying coaching as a significant predictor of reporting outcomes. The finding that coaching represents the strongest predictor of positive reporting culture in critical care settings merits particular attention. Critical care environments involve high-acuity patients, complex interventions, and substantial potential for adverse events, making effective reporting systems especially vital. That coaching behaviours prove particularly influential in these settings suggests that supportive supervisory relationships assume heightened importance under conditions of elevated stress and complexity.
The coaching findings also illuminate mechanisms through which leadership influences reporting. Unlike distal factors such as organisational policies or structural features, coaching behaviours represent proximal influences operating through direct interpersonal contact. This proximity may explain the particularly strong predictive relationships observed, as coaching behaviours directly shape the immediate social context within which reporting decisions occur.
Addressing the third objective regarding non-punitive approaches, the evidence convincingly demonstrates that blame culture substantially inhibits reporting whilst non-punitive responses enhance it. This finding aligns with established patient safety principles and reinforces the importance of just culture implementation. However, the evidence also reveals implementation challenges. Indriani, Kusumapradja and Anindita (2022) demonstrate that blame culture effects persist despite formal non-punitive policies, suggesting that espoused values and actual leadership behaviours may diverge in practice.
This gap between policy and practice carries significant implications for safety improvement efforts. Organisations cannot rely upon formal policy statements alone but must ensure that frontline supervisors consistently enact non-punitive responses. This requirement connects to broader leadership development needs, as supervisors may require specific training in responding constructively to error reports whilst maintaining appropriate accountability for genuinely reckless behaviour.
The fourth objective concerning relational and participative leadership receives support through the trust-building mechanisms identified by Jungbauer et al. (2018) and the participative style associations documented by Hernawati, Zulfendri and Nasution (2021). The leader-member exchange findings prove particularly theoretically significant, introducing reporting-specific trust as a mediating mechanism. This specificity suggests that generic trust measures may underestimate the importance of relationship quality for safety outcomes, as staff may hold differentiated trust beliefs regarding different domains of leader behaviour.
The fifth objective sought integrated understanding across leadership behaviour domains. Several integrative insights emerge from the synthesis. First, effective safety leadership appears multidimensional, incorporating cultural, interpersonal, emotional, and participative elements. Leaders who excel in single domains whilst neglecting others may achieve suboptimal outcomes. Second, the behaviours identified appear mutually reinforcing. Coaching relationships enable trust-building, trust enables honest communication about errors, and non-punitive responses validate the decision to report, potentially strengthening future coaching relationships.
Third, the evidence suggests that leadership influence on reporting operates through multiple pathways including motivation, capability, and opportunity. Transformational leadership enhances motivation by inspiring commitment to safety goals. Coaching builds capability by developing skills and confidence for reporting. Non-punitive cultures create opportunity by removing fear-based barriers. This multi-pathway influence suggests that comprehensive interventions addressing all three mechanisms may yield greatest improvements.
The findings carry significant implications for healthcare leadership development. Traditional leadership programmes may emphasise generic competencies such as communication, decision-making, or strategic thinking without specific attention to safety leadership behaviours. The evidence suggests value in developing programmes explicitly targeting the behaviours identified: intellectual stimulation, coaching provision, non-punitive responding, and trust-building. Such programmes might incorporate simulation exercises, role-play scenarios involving error disclosure conversations, and feedback mechanisms enabling leaders to assess their actual behaviours against intended approaches.
At organisational level, the findings suggest that safety culture interventions should address leadership behaviour as a modifiable factor alongside structural interventions such as reporting system design. Organisations might consider leadership behaviour assessment within safety culture surveys, enabling identification of units where leadership support for reporting requires strengthening. Executive leaders might model desired behaviours through visible engagement with safety events, transparent communication about lessons learned, and explicit recognition of staff who contribute to safety improvement through reporting.
The evidence also carries policy implications for healthcare regulation and accreditation. Regulatory frameworks increasingly emphasise safety culture assessment, yet may focus primarily on structural indicators such as reporting system existence rather than cultural indicators such as leadership behaviour quality. Incorporating leadership behaviour assessment within regulatory frameworks could incentivise organisational attention to this modifiable factor.
Conclusions
This dissertation has systematically examined evidence regarding leadership behaviours that predict incident reporting and organisational learning in hospital settings. The synthesis demonstrates that four leadership behaviour domains consistently emerge as significant predictors: transformational approaches emphasising intellectual stimulation and idealised influence; coaching behaviours providing feedback, guidance, and reflective support; non-punitive responses maintaining just culture principles; and participative relational styles building trust and engagement.
The first objective has been achieved through examination of transformational leadership evidence, demonstrating consistent associations with enhanced safety culture and increased reporting practices across diverse hospital settings. The intervention evidence proves particularly valuable in suggesting causal relationships amenable to leadership development interventions.
The second objective regarding coaching behaviours has been addressed through analysis of evidence identifying coaching as strongly predictive of reporting intention and culture, with critical care findings highlighting its particular importance in high-acuity settings. The mechanisms through which coaching operates, including feedback provision and reflective dialogue, have been elucidated.
The third objective concerning non-punitive approaches has been achieved through synthesis demonstrating that blame culture substantially inhibits reporting whilst non-punitive responses enhance it. The gap between formal policies and enacted behaviours has been identified as a significant implementation challenge.
The fourth objective regarding relational and participative leadership has been addressed through examination of leader-member exchange and participative leadership evidence, identifying trust-building as a key mediating mechanism linking relationship quality to reporting outcomes.
The fifth objective seeking integrated understanding has been achieved through identification of complementary mechanisms and multi-pathway influences, suggesting that comprehensive leadership approaches incorporating multiple behaviour domains yield optimal outcomes.
The significance of these findings extends across theoretical, practical, and policy domains. Theoretically, the synthesis advances understanding of how leadership shapes safety culture through specific behavioural mechanisms operating at cultural, interpersonal, and psychological levels. Practically, the findings provide evidence-based guidance for leadership development programmes and organisational safety improvement efforts. From a policy perspective, the evidence supports regulatory attention to leadership behaviour quality as a modifiable factor influencing patient safety outcomes.
Future research might productively address several directions suggested by this synthesis. Longitudinal studies tracking leadership behaviour changes and subsequent safety culture outcomes would strengthen causal inference. Implementation research examining how organisations successfully develop leadership behaviours identified as high-impact would enhance practical guidance. Comparative studies across healthcare systems with different regulatory and cultural contexts would test generalisability of current findings. Finally, economic evaluation of leadership development interventions targeting safety leadership competencies would inform resource allocation decisions.
In conclusion, leadership behaviour represents a significant and modifiable predictor of incident reporting and organisational learning in hospitals. Leaders who combine transformational vision with coaching support, maintain consistent non-punitive responses, and build trusting participative relationships create conditions enabling robust safety cultures. Cultivating these leadership behaviours across healthcare organisations represents a promising pathway for strengthening patient safety systems and ultimately reducing preventable harm.
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