Received: 12 April 2019 | Revised: 19 June 2019 | Accepted: 8 September 2019

DOI: 10.1002/nop2.386

RESEARCH ARTICLE

Linking transformational leadership, patient safety culture and

work engagement in home care services

Eline Ree | Siri Wiig

SHARE – Centre for Resilience

in Healthcare, Faculty of Health Abstract
Sciences, University of Stavanger, Stavanger, Aim: To assess the relationship between transformational leadership, job demands,
Norway
job resources, patient safety culture and work engagement in home care services.
Correspondence Design: Cross‐sectional survey.
Eline Ree, SHARE – Centre for Resilience
in Healthcare, Faculty of Health Sciences, Methods: Healthcare professionals in Norwegian home care services participated
University of Stavanger, Stavanger N‐4036, in the study (N = 139). Multiple regression analyses with patient safety culture and
Norway.
Email: eline.ree@uis.no work engagement as outcomes and transformational leadership, job demands, job
resources as predictors were conducted.
Funding information
The work is part of the project Improving Results: The transformational leadership model explained 35.7% of the variance in
Quality and Safety in Primary Care –
patient safety culture. Adding job demands and resources and work engagement to
Implementing a Leadership Intervention in
Nursing Homes and Homecare (SAFE‐LEAD the model increased the explained variance to 53.5%. The job resource “skill utiliza‐
Primary Care), which has received funding
tion” was the strongest predictor of work engagement. The full model with all predic‐
from the Research Council of Norway's
programme HELSEVEL, under grant tor variables explained 28.2% of work engagement.
agreement 256681/H10, and the University
Conclusion: Transformational leadership has a significant impact on patient safety
of Stavanger.
culture and work engagement in home care services. Employees' perceptions of job
demands, available resources and engagement also affect patient safety culture.

KEYWORDS
job demands, job resources, patient safety culture, transformational leadership, work
engagement

1 | I NTRO D U C TI O N fewer adverse events (Wang et al., 2014). To increase knowledge on

how to improve patient safety culture, more research on the factors
In this study, we explore whether transformational leadership, job that affect it is needed.
demands and job resources influence patient safety culture and In a comprehensive review of the literature on safety culture
work engagement in Norwegian home care services. Patient safety in the U.S. hospital setting, it is suggested that a “culture of safety
culture can be defined as “the product of individual and group val‐ begins with leadership” (Sammer, Lykens, Singh, Mains, & Lackan,
ues, attitudes, perceptions, competencies and patterns of behaviour 2010). The authors argue that leaders have a key role in designing,
that determine the commitment to and the style and proficiency of, encouraging and developing a safety culture. The role of patient
an organization's health and safety management” (ACSNI, 1993). safety culture and leadership has also been pinpointed as key chal‐
Research has shown that a poor patient safety culture is associated lenges in public inquiries into system failures that were allowed to
with injuries to both nurses and patients (Taylor et al., 2012). A good develop over years and caused serious injury of death of numerous
safety culture is associated with patients' safety‐related outcomes, patients, as in the Mid staffordshire (Francis, 2013) and Bristol cases
such as increased patient satisfaction (Hofmann & Mark, 2006) and (Kennedy, 2001). The aftermath of these healthcare disasters has

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2019 The Authors. Nursing Open published by John Wiley & Sons Ltd.

256 | wileyonlinelibrary.com/journal/nop2
 Nursing Open. 2020;7:256–264.
REE and WIIG | 257

focused on managers' responsibility in building cultures for safety harm by highlighting leadership and the safety culture (Skjellanger
and learning. et al., 2014). A new national regulation in Norway emphasizes man‐
Several studies emphasize the role of leaders in building a safety agers' responsibility for quality and patient safety work (Ministry of
culture (Merrill, 2015; Wagner et al., 2018; Wong, Cummings, & Health & Care Services, 2016).
Ducharme, 2013). McFadden, Henagan, and Gowen (2009) found
that transformational leadership was directly related to patient
safety culture and indirectly related to patient safety outcomes 2 | BAC KG RO U N D
through culture and patient safety initiatives, such as education and
training of employees and system redesign. Transformational lead‐ The research on leadership in relation to patient safety in the home
ership occurs “when leaders broaden and elevate the interests of care context is scarce. Patient safety research in home care services is
their employees, when they generate awareness and acceptance limited, as most of the literature on safety culture centres on hospitals
of the purposes and mission of the group and when they stir their and acute care settings (Gartshore, Waring, & Timmons, 2017) in addi‐
employees to look beyond their own self‐interest for the good of tion to some recent studies from Norwegian nursing homes (Cappelen,
the group” (Bass, 1991, p. 21). In a meta‐analytic review, Clarke Aase, Storm, Hetland, & Harris, 2016; Cappelen, Harris, & Aase, 2018).
(2013) suggested that transformational leadership was associated One study has explored perceptions of the patient safety culture in
with encouraging employee participation in safety. Furthermore, a Norwegian home care services (Olsen & Bjerkan, 2017). Furthermore,
systematic review of the relationship between nursing leadership to the best of our knowledge, no studies have explored the impact of
and patient outcomes concluded that transformational leadership is transformational leadership on patient safety culture and work engage‐
positively related to improved patient outcomes, such as increased ment in home care services and whether job demands, and resources
patient satisfaction and fewer adverse events and complications help to explain these outcomes. The aims of this study are therefore
(Wong et al., 2013). to explore (a) the degree to which transformational leadership, job de‐
The relationship between transformational leadership and pa‐ mands and resources and work engagement can explain patient safety
tient safety might partly be a result of managers' role in creating a culture in home care services; and (b) the degree to which transfor‐
sound work environment that balances job demands and resources mational leadership and job demands and resources, can explain work
(Boamah, Laschinger, Wong, & Clarke, 2018), as well as their influ‐ engagement among home healthcare personnel. Based on previous
ence on employees' work engagement (Salanova, Lorente, Chambel, research and theory, the following hypotheses are postulated:
& Martínez, 2011). According to Salanova et al. (2011), there is a di‐
rect link between transformational leadership and employees' work Hypothesis 1: 
Transformational leadership, job re‐
engagement. However, based on the job demand and job resources sources and work engagement are pos‐
model arguing that engagement is largely a result of job resources itively related to patient safety culture,
and manageable job demands (Bakker & Demerouti, 2007), the link while job demand is negatively related
might also be indirect through working conditions. A study of acute to patient safety culture.
care nurses in Ontario, Canada, found that transformational leader‐
ship behaviours had a positive influence on workplace conditions, Hypothesis 2: Transformational leadership is a stron‐
which were then related to fewer adverse patient outcomes and ger predictor for patient safety culture
greater job satisfaction among nurses (Boamah et al., 2018). than job demands, job resources and
Several studies argue for the importance of work environment work engagement.
for patient safety (Nahrgang, Morgeson, & Hofmann, 2011; Olds,
Aiken, Cimiotti, & Lake, 2017; Sturm et al., 2019). Similarly, employee Hypothesis 3: Transformational leadership and job re‐
engagement is found to be associated with patient safety culture sources are positively related to work
(Biddison, Paine, Murakami, Herzke, & Weaver, 2016). A review by engagement, while job demand is nega‐
Mossburg and Dennison (2018) found that most studies reported tively related to work engagement.
a moderately strong association between engagement and patient
safety culture. The review concluded, however, that the engage‐ Hypothesis 4: Transformational leadership is a stron‐
ment/safety literature is immature and there is a need for more re‐ ger predictor for work engagement
search on this topic. than job demands and job resources.
National health policy documents and patient safety campaigns
and programs have shown a strong focus on building structures and
a culture for patient safety and that leaders are playing a key role in
its success. In Norway, for example, the national campaign “In Safe 3 | M E TH O DS
Hands” was launched in 2011 by the Norwegian Ministry of Health
and Care Services, to improve patient safety and reduce patient This study used a cross‐sectional survey design.
258 | REE and WIIG

developed and validated by Cappelen et al. (2016). The instru‐

3.1 | Setting, sample and data collection
ment consists of 41 items that measure health personnel's percep‐
The questionnaire was distributed to 206 participants, with 139 tions of patient safety culture, rated on 5‐point Likert scales. In this
responding (response rate of 67.5%). Co‐researchers from the study, some of the items in the Norwegian nursing home version by
Development Centres of Nursing Home and Home Care Services Cappelen et al. (2016) were slightly adjusted to fit the home care
helped with the recruitment by initiating contact with the unit man‐ setting. The only adjustments made were the change in some words,
agers of the included home care units (Wiig et al., 2018). A purpose‐ for instance, replacing “nursing home” with “unit” or “home care.”
ful sampling strategy was used, strategically selecting four units from In this study, all 41 items were computed as a mean score and used
four municipalities in south‐western Norway that varied in size, unit as an outcome measuring the total patient safety culture score. The
size and location (urban and rural) (Table 1). Inclusion criteria were Cronbach's alpha value of this total score was .88. Previous stud‐
that the employees had to be employed in at least a 30% position ies have demonstrated an acceptable fit of a 10‐factor model of the
and capable of writing in the Norwegian language. Questionnaires scale in Norwegian settings (Cappelen et al., 2016, 2018). The 10
were distributed through e‐mail to all participants in April 2018. factors are “teamwork,” “staffing,” “compliance with procedures,”
In Norway, home care services and nursing homes are organized “training and skills,” “nonpunitive responses to mistakes,” “handoffs,”
and provided by municipalities, implying that the management roles “feedback and communication about incidents,” “communication
and responsibilities are similar in both settings. Moreover, this implies and openness,” “supervisor expectations and actions promoting pa‐
that all healthcare staff in both nursing homes and home care are tient safety” and “organizational learning” (Cappelen et al., 2016).
municipal employees. Municipalities are responsible for primary care
services in Norway such as general practitioners, emergency rooms,
3.2.2 | Transformational leadership
nursing homes and home care services. The organizational structure
of the units differed somewhat because of variations in geography, Transformational leadership was measured using the Global
size and local circumstances. In the smallest municipality (HCS C), Transformational Leadership Scale (GTL) (Carless, Wearing, &
employees often shared responsibility across departments and could Mann, 2000). Staff were asked to rate the leadership style of their
take shifts in both nursing homes and home care services as needed. nearest leader on seven items rated on 5‐point Likert scales rang‐
However, they responded to the home care survey if they worked ing from “never” to “very often.” Examples of items are as follows:
most of their position in the home care services. All home care ser‐ “Encourages thinking about problems in new ways and questions as‐
vices provided home nursing and practical assistance to people in sumptions; and “Treats staff as individuals, supports and encourages
need of such services. All municipalities were organized under a di‐ their development.” Carless et al. (2000) found GTL to have high de‐
rector of health and welfare services at the municipal level who was gree of convergent validity with the more extensive and established
responsible for all healthcare services delivered in the municipality. In Multifactor Leadership Questionnaire (MLQ) (Avolio, Bass, & Jung,
our study, each unit had a unit manager with personnel responsibility 1995). In this study, Cronbach's alpha was .93.
for the whole organization. Three of the units (HSC B–D) also had one
department manager, while the largest unit (HCS A) had three depart‐
3.2.3 | Job demands and job resources
ment managers, one for each of the three departments in the unit.
Job demands and job resources were measured with the Short
Inventory to Monitor Psychosocial Hazards (SIMPH) (Notelaers, De
3.2 | Instruments
Witte, Van Veldhoven, & Vermunt, 2007), which is based on the
Job Demands–Resources model by Demerouti, Bakker, Nachreiner,
3.2.1 | Patient safety culture
and Schaufeli (2001). The scale consists of 24 items rated on 4‐
Patient safety culture was measured by the Norwegian version of point Likert scales (1 = never to 4 = always). Job demands consist
the Nursing Home Survey on Patient Safety Culture (NHSOPSC), of three dimensions: (a) pace of work (4 items, e.g. “Do you work
under time constraints?”); (b) mental workload (3 items, e.g. “Do you
have to focus your attention on several things simultaneously?”);
TA B L E 1 Study setting
and (c) emotional workload (5 items, e.g. “Is your work heavy from
Unit Municipality an emotional viewpoint?”). Cronbach's alpha values were .91 (pace
HCS A 250–300 users Large district of work); .81 (mental workload); and .77 (emotional workload). Job
ca. 30 min to hospital 15–20,000 inhabitants resources consist of three dimensions: (a) skill utilization (4 items,
HCS B 200–250 users City e.g. “Do you feel that you achieve something meaningful in your
ca. 20 min to hospital 70–75,000 inhabitants job?”); (b) autonomy (four items, e.g. “Do you have an influence on
HCS C 200–250 users Small district the pace of work?”); and (c) participation (4 items, e.g. “Can you
ca. 1 hr to hospital <5,000 inhabitants participate in decisions affecting areas related to your work?”).
HCS D 50–100 users Medium‐sized district Cronbach's alpha values were .77 (skill utilization), .68 (autonomy)
ca. 20 min to hospital 5,000–10,000 inhabitants
and .82 (participation).
REE and WIIG | 259

TA B L E 2 Descriptive sample
Years of
information (N = 139)
Occupational status N (%) employment N (%)

Managerial position 9 (6.5) <1 6 (4.3)

Health personnel with min. 3 years 59 (42.4) 1–5 38 (27.3)
higher education
Health personnel with high school 56 (40.3) 6–10 35 (25.2)
education
Healthcare assistant (unskilled) 12 (8.6) 11–15 19 (13.7)
Administrative personnel 1 (0.7) 16–20 29 (20.9)
Other 2 (1.4) =>21 12 (8.6)

TA B L E 3 Means, standard deviations (SD) and Pearson correlations between independent and dependent variables

Variables Mean SD 1 2 3 4 5 6 7 8 9

1. Patient safety 3.77 0.39 1

culture
2. Transformational 3.47 0.81 .59** 1
leadership
3. Work pace 2.57 0.63 −.42** −.18* 1
**
4. Mental workload 2.95 0.61 −.25 −.11 .64** 1
** **
5. Emotional workload 1.96 0.40 −.43 −.37 .40** .47** 1
** **
6. Skill utilization 2.85 0.52 .36 .50 −.11 .15 −.20** 1
** ** **
7. Autonomy 2.42 0.45 .29 .31 −.28 −.11 −.27** .49** 1
** ** ** ** **
8. Participation 2.54 0.55 .49 .50 −.30 −.08 −.24 .48 .53** 1
** ** * **
9. Engagement 5.48 1.1 .39 .40 −.14 −.05 −.18 .45 .29** .29** 1

*p < .05.
**p < .001.

was relatively even among the age categories: 20–29 years (10.1%),
3.3 | Statistical analyses
30–39 years (23.7%), 40–49 years (28.8%), 50–59 years (27.3%),
IBM SPSS Statistics version 25 was used for all the statistical analyses. 60+ years (10.1%). Most of the sample were healthcare personnel
There were no missing values in the data set, as each question had to with high school education or a minimum of 3 years of higher educa‐
be responded to before moving on to the next question in the survey. tion (Table 2). Years of employment ranged from less than 1–21 years
Pearson's correlations were used to assess the relationship or more (Table 2).
between the study variables and hierarchical multiple regression The means, standard deviations and inter‐correlations for study
analyses were used to examine how the explained variance of pa‐ variables are summarized in Table 3. As hypothesized, patient safety
tient safety culture and work engagement was distributed among culture had a significantly positive correlation with work engage‐
the predictors. Two multiple regression analyses were conducted ment, transformational leadership and the job resource dimensions
with patient safety culture and work engagement as outcomes. and a negative correlation with the job demand dimensions. Work
Transformational leadership, job demands (work pace, mental work‐ engagement had a significantly positive correlation with transfor‐
load, emotional workload), job resources (skill utilization, autonomy, mational leadership and the three job resources dimensions and
participation) were the independent variables in both analyses, as a negative correlation with the job demand dimension “emotional
well as work engagement in the analysis of patient safety culture. workload.”
Gender and years of employment were adjusted for in both analyses.
We conducted preliminary analyses of linearity, normality, multicol‐
4.1 | Patient safety culture
linearity and homoscedasticity, showing that none of the assump‐
tions for conducting multiple regression analyses were violated. In the multiple regression analysis of patient safety culture, with
gender, years of employment, transformational leadership, job
demands (work pace, mental workload, emotional workload), job
4 | R E S U LT S resources (skill utilization, autonomy, participation) and work en‐
gagement, transformational leadership was, as hypothesized, the
The sample consisted of 139 home healthcare services employ‐ strongest predictor (β = .30 p < .001) (Table 4). The model containing
ees, most of whom were female (96.4%). The distribution of age only the transformational leadership variable explained 35.7% of the
260 | REE and WIIG

TA B L E 4 Hierarchical regression
Patient safety culture
analysis for variables predicting patient
Model 1 Model 2 Model 3 Model 4 Model 5 safety culture (N = 139)

Variables β β β β β
Gender −.018 .028 −.028 −.036 −.025
Years employed −.257* −.110 −.121 −.127 −.160
Transformational leadership .561** .439** .353** .303**
Work pace −.335** −.285* −.280*
*
Emotional workload −.185 .086 .105
Mental workload .115 −.188* −.197
Skill utilization .005 −.066
Autonomy −.066 −.079
*
Participation .215 .223*
Work engagement .191*
2
R .066 .357 .482 .509 .535
F for change in R2 4.81* 61.21** 10.58** 2.33 7.180*

*p < .05.
**p < .001.

variance in patient safety culture, while the full model, including all of transformational leadership decreased substantially when the job
predictors explained 53.5% of the variance. In addition to transfor‐ resources dimensions were included in the model, but remained a sig‐
mational leadership, participation (β = .22 p < .05) and work engage‐ nificant positive predictor in the final model (β = .26 p < .05). None of
ment (β = .19 p < .05) had a significantly positive impact on patient the other predictor variables had a significant impact on work engage‐
safety culture; work pace (β = −.28 p < .05) had a negative impact. ment. The model containing only the transformational leadership vari‐
able explained 17.5% of the variance in work engagement, while the
full model, including all predictors explained 28.2% of the variance.
4.2 | Work engagement
In the multiple regression analysis of work engagement, with gen‐
der, years of employment, transformational leadership, job demands 5 | D I S CU S S I O N
(work pace, mental workload, emotional workload) and job resources
(skill utilization, autonomy, participation), skill utilization was the The central purpose of this study was to examine the associations
strongest predictor (β = .37 p < .001) (Table 5). The predictive value between patient safety culture, transformational leadership, job

TA B L E 5 Hierarchical regression
Work engagement
analysis for variables predicting work
Model 1 Model 2 Model 3 Model 4 engagement (N = 139)

Variables β β β β
Gender −.045 −.009 −.028 −.057
Years employed .009 .123 .119 −.174
Transformational leadership .432** .411** .259*
Work pace −.115 −.026
Emotional workload .060 −.102
Mental workload −.015 .051
Skill utilization .372**
Autonomy .067
Participation −.043
R2 .002 .175 .183 .282
F for change in R2 0.144 28.33** 0.435 5.89*

*p < .05.
**p < .001.
REE and WIIG | 261

demands and resources and work engagement. The results sup‐ opportunities for personal growth and development, to learn new
ported the first hypothesis, as transformational leadership, job things and to achieve something meaningful, is important for em‐
resources and work engagement were all positively related to pa‐ ployees' work engagement.
tient safety culture and job demands was negatively related to it. A recent study of 675 Belgian home care nurses found that
The second hypothesis was also supported, showing that trans‐ job resources were related to greater work engagement and less
formational leadership was a stronger predictor for patient safety burnout (Vander Elst et al., 2016). Similarly, a meta‐analytic study
culture than job demands, job resources and work engagement. by Nahrgang et al.. (2011) showed that job resources were related
The strong association found in this study between transforma‐ to engagement and safety outcomes. Their study looked at other
tional leadership and patient safety culture are consistent with types of resources, such as knowledge and a supportive and moti‐
previous research (Clarke, 2013; McFadden et al., 2009; Sfantou vating environment and explored the associations across industries
et al., 2017). Moreover, the results support the emphasis in inter‐ (Nahrgang et al., 2011). Although our study shows that job resources
national and national policies and guidelines on the importance are more important for work engagement than transformational
of leadership and culture in quality and patient safety work. It is leadership, managers might have an indirect effect on work en‐
argued that leadership is the key determinant in developing and gagement through their impact on job demands and job resources,
maintaining an organizational culture (Francis, 2013; Ministry of as suggested in a study by Schaufeli (2015). Our study suggests
Health & Care Services, 2016; West, Eckert, Steward, & Pasmore, that managers' effort in facilitating a proper balance between job
2014). In some countries, such as Norway, the essential role and demands and resources, as well as increasing employees' work en‐
responsibility of managers in leading quality and safety improve‐ gagement by giving them opportunities for utilizing their skills and
ment is strengthened in the regulations of the healthcare system competencies, might be possible paths through which leaders might
(Ministry of Health & Care Services, 2012, 2016; NOU, 2015). Our improve the patient safety culture.
study is the first to explore this association in Norwegian home
care services, implying a stronger evidence base for policymakers'
5.1 | Strengths and limitations
current emphasis on the role of managers and leadership in devel‐
oping sound systems and culture for patient safety. In response To our best knowledge, with the exception of one previous study
to these findings, we argue that proper training and the further (Olsen & Bjerkan, 2017), this is the first Norwegian survey‐based
education of healthcare managers should include both theoretical study of patient safety culture in home care services and the first to
and practical insight into these areas, as this is often not part of explore the associations between leadership, job demands and re‐
their training. sources, work engagement and patient safety culture in this setting.
This study stands out, as it adds to previous research by explor‐ The sample diversity due to location (rural/urban) and municipality
ing job demands and resources, as well as engagement and how and unit size reduces the likelihood of localization‐ and group‐spe‐
these factors affect patient safety culture when adjusting for the cific effects.
role of leadership. Work pace (job demand), participation (job re‐ We had a theoretical and empirical rationale for the postu‐
source) and work engagement were also significant predictors of a lated relationships between the study variables. However, the use
patient safety culture. The negative relationship between job de‐ of a cross‐sectional design is a limitation when drawing inferences
mands and patient safety culture is in line with other research find‐ about causal relationships, because all variables are assessed at the
ings (Phipps, Malley, & Ashcroft, 2012; Ramanujam, Abrahamson, same point in time (Kestenbaum, 2009). Thus, future studies should
& Anderson, 2008). Phipps et al. (2012) suggest, however, that if explore the relationship between the study variables using a longi‐
staff members are highly motivated and have adequate resources tudinal design. Furthermore, as sub‐group analyses could not be jus‐
and support, their job demands might actually facilitate safety im‐ tified in this study due to the small sample size, future studies should
provement. Managers play a key role in balancing job demands with explore whether these relationships differ across occupations. For
job resources (Schaufeli, 2015), which in turn are related to patient example, Wagner et al. (2018) found that hospital physicians and
safety culture. nurses differed in their perceptions of patient safety culture, with
This study partially supports the third hypothesis, in that trans‐ physicians rating the culture more positively than nurses did.
formational leadership and job resources were positively related Caution should be used when generalizing the results, as the
to work engagement and the work demand dimension “emotional sample was small and selected purposively based on the units' par‐
workload” was negatively related to work engagement. However, ticipation in an intervention project (Wiig et al., 2018). However, it
the work demand dimensions “work pace” and “mental workload” is difficult to recruit participants in this setting and the validity is
did not correlate significantly with work engagement. The last hy‐ strengthened by the high response rate of 67.5%. For comparison,
pothesis in this study, that transformational leadership is a stronger the other Norwegian study on patient safety culture in home care
predictor for work engagement than job demands and job resources, had a response rate of 28% (Olsen & Bjerkan, 2017). The great pre‐
must be rejected, as the job resource “skill utilization” turned out to dominance of women in the sample is representative for the home
be the strongest single predictor for work engagement. Thus, em‐ care setting in general (Helsedirektoratet, 2017), but caution should
ployees' perceptions that their work is varied, providing them with be used when generalizing to men and to other healthcare sectors.
262 | REE and WIIG

6 | CO N C LU S I O N S A N D I M PLI C ATI O N S interpretation of data and writing of the first draft of the manu‐
script. SW was responsible for the application for funding, recruit‐
This study found that transformational leadership behaviours has a ment, designing the study, data collection and commenting on
significant impact on patient safety culture and work engagement in drafts of the manuscript. Both authors have approved the final
home care services. Job demands and resources and work engage‐ version.
ment also affect patient safety culture. The findings of this study
highlight the importance of managers' use of transformational lead‐
E T H I C A L A P P R OVA L
ership in increasing work engagement among employees and im‐
proving patient safety culture in home care services. The Regional Committees for Research Ethics in Norway found
From an organizational perspective, we recommend education that the study was not regulated by the Health Research Act. The
and proper training of home care managers to increase their aware‐ Norwegian Social Science Data Services approved the study (NSD,
ness of leadership styles, patient safety culture and to strengthen ID 52324). The study followed the Helsinki Declaration, and all par‐
a transformational leadership style. Such interventions should also ticipants gave their informed consent.
stress the managers' role in facilitating employees' possibilities for
personal growth and development, participation in decision‐making
DATA AVA I L A B I L I T Y S TAT E M E N T
processes and ensuring a proper balance between job demands and
resources. From an organizational perspective, there is a need to Anonymized data sets of the study is available on request from the
provide managers with sufficient time and space to reflect on their corresponding author.
responsibility as role models and leaders in patient safety. There is a
need for collective reflexive spaces and arenas for home care man‐
ORCID
agers to discuss patient safety. Our research has demonstrated how
home care managers can take advantage of facilitated arenas and Eline Ree https://orcid.org/0000-0002-4268-5533
tools to support discussions of their role in developing a culture of Siri Wiig https://orcid.org/0000-0003-0186-038X
patient safety (Johannessen et al., 2019). From a policy perspective,
we recommend policy guidelines and regulations to enable making
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