Leadership Support and Patient Safety Culture in the Kingdom of Saudi Arabia: A Narrative Review

Full text

Text extracted from the article PDF for reading and search. Tables, figures and equations are in the PDF, which remains the authoritative version.

1. Introduction

Leadership support is well known as a cornerstone in the development and maintenance of a robust patient safety culture within healthcare systems, especially in complex and diverse organisational contexts (Mahsoon & Dolansky, 2021) [17]; (Alaska & Alkutbe, 2023) [3]. The culture of patient safety describes how common values, beliefs, and behavioural norms are applied to prioritise safety, communicate risks, and respond to errors by healthcare professionals (Agency for Healthcare Research and Quality, 2022) [2]; (Albaalharith & A’aqoulah, 2023) [4]. Leadership in this context is also crucial for developing safety-related attitudes and practices, particularly in nursing, where leaders are at the heart of care delivery and coordination (Atikah et al., 2022) [12]; (Rawas & Abou Hashish, 2023) [21]. It is anticipated that nursing leaders not only guide clinical practice but also encourage open communication, accountability, and psychological safety, which are the preventive factors of harm and patient outcomes (Mahsoon and Dolansky, 2021) [17]; (Al-Surimi et al., 2022) [11].

Leadership behaviours can have a very profound impact on safety behaviours, reporting practices, and the quality of care provided in general, since they have a direct effect on frontline staff (Rawas & Abou Hashish, 2023) [21]; (Binkheder et al., 2023) [13].

The interaction between leadership support and patient safety culture has been the subject of extensive investigation in Saudi Arabian healthcare environments, and it is increasingly evident that leadership commitment is an essential predictor of safety culture outcomes (Alaska & Alkutbe, 2023) [3]; (Algethami et al., 2024) [6]. Empirical research conducted in tertiary hospitals, primary healthcare centres, and national healthcare systems in Saudi Arabia consistently yields the same results: leadership support is closely correlated with enhanced teamwork, openness to communication, and organisational learning (Aljaffary et al., 2022) [7]; (Alrasheeday et al., 2024) [9]. On the other hand, the lack of leadership engagement has been associated with a weaker safety culture, less frequent incident reporting, and greater adverse and sentinel events (Binkheder et al., 2023) [13]; (Aboufour & Subbarayalu, 2022) [1]. Such results highlight the necessity of leadership approaches that are responsive to the complexity of organisations and workforce diversity within Saudi healthcare settings (Atikah et al., 2022) [12]; (Alaska & Alkutbe, 2023) [3].

The organisational structure of Saudi Arabia, the diverse multicultural workforce, and the intensive use of expatriate nurses impose unique challenges on the healthcare leaders in the Kingdom of Saudi Arabia (Mahsoon & Dolansky, 2021) [17]; (Albalawi et al., 2020) [5]. Such contextual features might make communication, cooperation, and joint decision-making more complicated, which adds the possibility of underreporting errors and silencing safety-related issues (Atikah et al., 2022) [12]; (Aboufour & Subbarayalu, 2022) [1]. Strong authority gradients and high-power distance might also deter frontline employees from voicing concerns, especially in settings where correctional reactions to mistakes are seen or felt (Almuntasheri & Almandeel, 2022) [8]; (Al-Surimi et al., 2022) [11]. Consequently, the culture of patient safety might be weak even in the case of existing formal policies and reporting systems (Albalawi et al., 2020) [5]; (Albaalharith and A’aqoulah, 2023) [4].

The challenges could be considered through the prism of the Leadership styles based on the Path-Goal Leadership Theory 2023) [10]. It is a theory that focuses on adaptive leadership, which argues that leaders ought to change their behaviours in accordance with the requirements of the staff members, the nature of the tasks, and the needs of the organisations so as to improve motivation, performance, and productivity (Murray et al., 2018) [19]; (Al-Shakhis and Banks-Santilli, 2023) [10]. This flexibility is particularly applicable to Saudi nursing units that are usually staffed by multicultural teams with different communication preferences, professional demands, and perceptions of safety (Albalawi et al., 2020) [5]; (Ismail & Khalid, 2022) [16]. Nurse leaders can potentially be more effective in fostering the culture of psychological safety, open communication, and the culture of robust incident reporting, which are three fundamental areas of patient safety culture in Saudi studies (Albalawi et al., 2020) [5]; (Alrasheeday et al., 2024) [9].

The system of healthcare in Saudi Arabia has recently changed significantly as a part of the Vision 2030 agenda that focuses on improving the quality of healthcare, its efficiency, and patient-centred care (Almuntasheri & Almandeel, 2022) [8]; (Algethami et al., 2024) [6]. In spite of these reforms, patient safety continues to be a burning issue, and research indicates that there is still a gap in safety culture and that medical errors have continued to occur in healthcare settings (Almuntasheri & Almandeel, 2022) [8]; (Binkheder et al., 2023) [13]. Studies also show that the organisational settings promoting the hierarchical structure and the lack of leadership involvement in safety efforts can prevent both appropriate communication and error learning, thus deteriorating patient safety culture despite system-wide reforms (Albalawi et al., 2020) [5]; (Aljaffary et al., 2022) [7]. The support of leadership has been specifically practical in the development of psychological safety and open communication in healthcare teams (Agency for Healthcare Research and Quality, 2022) [2]. It has been demonstrated that supportive leadership behaviours, including emotional and professional support, emphasis on teamwork, and inclusion of staff in making joint decisions, can establish the environments where healthcare professionals feel free to report mistakes without any fear of blame and punishment (Mahsoon & Dolansky, 2021) [17]; (Rawas & Hashish, 2023) [21]. The evidence related to Saudi Arabia proves that the support offered by the leadership is positively correlated with job satisfaction, lower intention to leave, and better safety outcomes among healthcare workers (Al-Surimi et al., 2022) [11]; (Rawas & Hashish, 2023) [21]. These findings demonstrate leadership support as a key tool of maintaining a positive patient safety culture (Alaska & Alkutbe, 2023) [3]. Nevertheless, the impact of cultural beliefs that are typified by high-power distance and high-authority dependence might restrict the efficiency of the leadership styles of inclusiveness and empowerment, like transformational leadership, in Saudi healthcare settings (Atikah et al., 2022) [12]. In this Aspect, the adaptive leadership model of the Path-Goal Leadership Theory can provide a contextually suitable model to Saudi healthcare organisations (Murray et al., 2018) [19]; (Al-Shakhis and Banks-Santilli, 2023) [10]. By adjusting the leadership behaviours in accordance with the staff experience, team dynamics, and organisational climate, leaders will be able to balance hierarchical expectations with engagement and empowerment, eventually improving patient safety outcomes (Murray et al., 2018) [19]; (Albalawi et al., 2020) [5].

This narrative review aims to add to theoretical and practical knowledge by summarising the existing literature on the topic of leadership support and patient safety culture in the Saudi Arabian healthcare setting (Mahsoon & Dolansky, 2021) [17]; (Alaska & Alkutbe, 2023) [3]. With the help of a thematic synthesis and a conceptual framework based on the Path-Goal Leadership Theory, this review will seek to establish leadership approaches that could be successfully utilized to address contextual complexities and improve the patient safety culture (Murray et al., 2018) [19]; (Atikah et al., 2022) [12]. With Saudi Arabia still progressing in its healthcare transformation, organisational and country-specific leadership practices will be important in maintaining changes in patient safety and quality of care (Mahsoon & Dolansky, 2021) [17]; (Algethami et al., 2024) [6].

2. Materials and Methods

The research was in a narrative review design to synthesise and critically analyse the available literature on the topic of leadership support and patient safety culture in healthcare facilities, focusing on nursing leadership and the Saudi Arabian context. The narrative approach has been chosen in order to enable the theoretical integration, contextual interpretation, and thematic exploration of a variety of empirical, conceptual, and policy-oriented sources. The overall strategy of keywords was applied, combining the following terms: leadership support, nurse leadership, patient safety culture, safety leadership, Path-Goal Leadership Theory, Saudi Arabia, psychological safety, management support, teamwork, staffing, communication openness, and error reporting. Peer-reviewed empirical studies, policy reports, review articles, and theoretical papers that covered the leadership and patient safety culture in healthcare organisations were all eligible. Articles that were not in full text were excluded, as well as those published not in English and those that did not have obvious relevance to leadership or patient safety culture. After the screening, the corresponding articles were read, and data about the leadership styles, safety culture dimensions, theoretical frameworks, and organisational factors were extrapolated systematically.

Thematic analysis guided the synthesis of findings, enabling the identification and organisation of recurring patterns and concepts in the chosen literature. Psychological safety, openness of communication, leadership support, teamwork, staffing, and error reporting were considered as key themes that put structure in the narrative synthesis and provided the conceptual framework based on the Path-Goal Leadership Theory. Since this review was not conducted systematically but narratively, it did not use exhaustive search protocols or formal quality appraisal tools, and the possibility of selection bias cannot be completely ruled out. Moreover, causal inference is not possible because the included literature is dominated by cross-sectional research. However, the narrative approach offered a holistic, contextualized perspective on leadership support and patient safety culture, thereby facilitating an understanding of the theoretical and practical implications of leadership in healthcare in Saudi Arabia.

2.1. Literature Search Strategy

To have a broad scope of health, nursing, leadership, and patient safety research, the literature search was done in various electronic databases, such as PubMed, Scopus Web of Science, and Google Scholar. Only the English-language publications published in 1921 - 2025 were included in the search, as this period marked the development of the current theories on leadership and the transformation of the patient safety culture research.

2.2. Study Selection Criteria

The overall strategy of keywords was applied, combining the following terms: leadership support, nurse leadership, patient safety culture, safety leadership, Path-Goal Leadership Theory, Saudi Arabia, psychological safety, management support, teamwork, staffing, communication openness, and error reporting. Peer-reviewed empirical studies, policy reports, review articles, and theoretical papers that covered the leadership and patient safety culture in healthcare organisations were all eligible. Articles that were not in full text were excluded, as well as those published not in English and those that did not have obvious relevance to leadership or patient safety culture. After the screening, the corresponding articles were read, and data about the leadership styles, safety culture dimensions, theoretical frameworks, and organisational factors were extrapolated systematically.

Thematic analysis guided the synthesis of findings, enabling the identification and organisation of recurring patterns and concepts in the chosen literature. Psychological safety, openness of communication, leadership support, teamwork, staffing, and error reporting were considered as key themes that put structure in the narrative synthesis and provided the conceptual framework based on the Path-Goal Leadership Theory. Since this review was not conducted systematically but narratively, it did not use exhaustive search protocols or formal quality appraisal tools, and the possibility of selection bias cannot be completely ruled out. Moreover, causal inference is not possible because the included literature is dominated by cross-sectional research. However, the narrative approach offered a holistic, contextualized perspective on leadership support and patient safety culture, thereby facilitating an understanding of the theoretical and practical implications of leadership in healthcare in Saudi Arabia.

3. Results

3.1. Patient Safety and Leadership.

There exist strong connections between leadership and patient safety culture in modern healthcare systems that are highly represented in the literature. The commitment of leadership is always listed as a primary defining factor in the patient safety culture because leaders influence the organisational priorities, norms, and expectations regarding safety practices (Agency for Healthcare Research and Quality, 2022) [2]; (Mahsoon & Dolansky, 2021) [17]. In terms of their behaviours, communication patterns, and their choice of resource distribution, leaders have a significant impact on the working conditions of the healthcare professionals, especially those on the front line of care delivery (Agency for Healthcare Research and Quality, 2022) [2]; (Rawas & Hashish, 2023) [21]. Regardless of this general understanding, empirical studies that directly relate leadership behaviours to quantifiable patient safety events are scarce, with most researchers indicating that leadership is indirectly related to patient safety via behavioural and cultural intermediates (Murray et al., 2018) [19]; (Alaska & Alkutbe, 2023) [3]. It is suggested, therefore, that supporting leadership contributes positively to psychological safety, which further leads to the reporting of errors, learning mistakes, and continuous improvement (Murray et al., 2018) [19]; (Ismail & Khalid, 2022) [16]. Other researchers, on the other hand, focus on the structural Aspect of leadership and argue that the power of governance mechanisms, staffing choices, and implementing safety policies can have a more significant effect on patient safety than the effect of interpersonal leadership behaviours (Almuntasheri & Almandeel, 2022) [8]; (Binkheder et al., 2023) [13].

These points of view may have different focuses, but all of them lead to the realization that patient safety culture can be reinforced only with the help of leadership. One of them emphasises empathy, trust, and relational interaction, whereas the other is accountable, system design, and formal safety controls (Mahsoon & Dolansky, 2021) [17]; (Almuntasheri & Almandeel, 2022) [8]. By promoting trust and transparency, leaders allow staff to develop, empower practitioners to voice their issues without fear, and express their visible concern toward patient safety, thus enhancing the wellbeing of the staff and patient outcomes (Mahsoon & Dolansky, 2021) [17]; (Rawas & Abou Hashish, 2023) [21]. This type of leadership, which entails guidance and providing resources enough, also strengthens safety behaviours through instilling psychological safety as a routine (Albalawi et al., 2020) [5]; (Alrasheeday et al., 2024) [9]. Organisational learning is more effective, and safety culture is reinforced when healthcare professionals are not punished in cases when reporting mistakes (Albalawi et al., 2020) [5]; (Aboufour & Subbarayalu, 2022) [1]. The assertions are supported by empirical data that shows a regular correlation between leadership support, enhanced psychological safety among nurses, enhanced readiness to speak up, improved staff engagement and better patient safety outcomes (Ismail & Khalid, 2022) [16]; (Rawas & Abou Hashish, 2023) [21]. The lessons that can be learnt by the healthcare field with references to high-reliability organisations (HROs), including the aviation and nuclear industries, include the non-punitive nature of error reporting, shared consciousness, and learning on a global level (Albalawi et al., 2020) [5]. Nevertheless, it is a debatable issue whether HRO models can be directly transferred to the healthcare. Opponents state that healthcare demands more adaptive and empathetic leadership styles than the procedural rigidity that is frequently attributed to HROs due to the emotional labour, ethical complexity, and unpredictability of the sector (Murray et al., 2018) [19]; (Almuntasheri & Almandeel, 2022) [8]. The healthcare leaders are thus anticipated to not only eliminate the barriers to functioning but also offer emotional support, mentorship, and sufficient resources to staff to allow them to operate in a high-pressure and emotionally demanding setting (Mahsoon & Dolansky, 2021) [17]. Leaders can achieve this by promoting cultures where employees feel appreciated, capable, and motivated, which are the pillars of maintenance of a culture of patient safety by embracing adaptable and enabling leadership styles (Al-Surimi et al., 2022) [11]. All in all, the literature examined in this part of the paper confirms the fact that leadership and patient safety culture are closely connected, but there are divergent opinions about the nature of the mechanisms where leadership can bring change to safety outcomes. Other scholars assert the relational leadership behaviours, including emotional intelligence, and other researchers focus on the significance of organisational structures and interventions at the system level (Murray et al., 2018) [19]; (Almuntasheri & Almandeel, 2022) [8]. All these views support the idea of leadership as a key factor in patient safety, implying that the success of the leadership support depends on the leadership model that is taken in a particular healthcare environment (Mahsoon & Dolansky, 2021) [17]; (Alaska & Alkutbe, 2023) [3].

3.2. Patient Safety Saudi Arabian Culture. The case of the Kingdom of Saudi Arabia is a peculiar setting to explore the linkage between the leadership culture and the patient safety culture because of the complexity of its healthcare system. Regardless of significant changes implemented under the Vision 2030 in order to improve the quality of healthcare and service provision, patient safety remains an issue that should be given special attention (Almuntasheri & Almandeel, 2022) [8]; (Algethami et al., 2024) [6]. The statistics of claims related to medical errors at the national level demonstrate a significant growth in the number of claims, and it is reported that in 2011-2016, the number of claims grew by 37 percent, which indicates that the issue of safety is not addressed even with the interventions associated with the policies (Albalawi et al., 2020) [5]. Additional surveys have also been performed within the framework of Saudi hospitals where inadequate staffing, reaction to errors, and psychological safety continue to be significant weaknesses impacting the culture of safety and working conditions (Almuntasheri & Almandeel, 2022) [8]; (Alrasheeday et al., 2024) [9]. Moreover, the assessment of the national patient safety organisations has also revealed leadership gaps with the hierarchical organisation structure hindering the open communication and reporting of incidents due to cultural diversity (Albalawi et al., 2020) [5]; (Alaska & Alkutbe, 2023) [3].

Collective beliefs, organisational practices and collaboration patterns of healthcare teams determine the culture of patient safety in Saudi Arabia. A very diverse workforce, most of which consists of expatriate nurses, may cause difficulties in teamwork and communication, as well as the understanding of safety practices, especially in the situations when the staff is not familiar with the healthcare norms and systems in the country of operation (Moussa & Aboshaiqah, 2015) [18]; (Aboufour & Subbarayalu, 2022) [1]. Such cultural and professional dynamics require leadership styles that would focus on inclusiveness, empathy, and cultural competence to overcome communication barriers and improve safety outcomes (Mahsoon & Dolansky, 2021) [17]. Nevertheless, it is likely that the established cultural hierarchies and language barriers will constrain the participative leadership practices, especially in traditionally top-down management frameworks that are common in Saudi healthcare organisations (Almuntasheri & Almandeel, 2022) [8]; (Atikah et al., 2022) [12].

Even though structural changes, including policy implementation and staffing ratios are endorsed by some researchers, leadership mindset and behaviour are considered the main drivers of patient safety culture (Mahsoon & Dolansky, 2021) [17]; (Binkheder et al., 2023) [13]. Empathic leadership that is inclusive will help minimise the hierarchical separation and foster a common sense of safety commitment that is not limited to the organisation (Rawas & Abou Hashish, 2023) [21]. However, critics warn that leadership theories which were developed in the West such as transformational leadership might not be completely appropriate in the Saudi cultural norms with a high-power distance and dependency on authority (Atikah et al., 2022) [12]. This leads to a very important question of just how far global models of leadership such as transformational or Path-Goal leadership models can be successfully adapted to the Saudi healthcare environment.

3.3. Nurse Leadership and Culture of Safety. There are numerous reports focusing on nurse leadership as a foundation of patient safety, such as To Error Is Human (1999) and Keeping Patients Safe (2004) by the Institute of Medicine, which identifies leadership as a key component of the creation of effective safety systems. Nurse leaders work at the frontline and organisational levels, which places them in a position to influence the development of shared values, beliefs, and norms to support the culture of patient safety (Murray et al., 2018) [19]; (Rawas & Abou Hashish, 2023) [21]. In spite of this appreciation, there is still controversy on the best leadership model that can be used to promote patient safety. Transformational leadership has extensively been advocated because of its focus on empowerment, vision, and intrinsic motivation, which are attributed to fostering trust and innovation- qualities of a good safety culture (Mahsoon & Dolansky, 2021) [17]. Nevertheless, the applicability of the transformational leadership style in hierarchical and multicultural contexts of Saudi healthcare is a contentious issue, because its emphasis on a lower level of power distance and emotional involvement might go against existing organisational culture.

Other suggested models of leadership include authentic and servant leadership that emphasize transparency, trust, and psychological safety in healthcare (Almuntasheri & Almandeel, 2022) [8]. Although these models encourage open communication and employee welfare, critics say that they do not have the directive power needed when a crisis occurs or when a hierarchical system is inflexible (Albalawi et al., 2020) [5]. This has been an ongoing debate that shows a conceptual gap in the leadership theory since none of the leadership styles seems to be universally applicable in different healthcare settings. As a reaction to this shortcoming, the Path-Goal Leadership Theory provides a situational and flexible approach to leadership behaviour, where leaders can adjust their leadership behaviours to team requirements, task difficulty, and environmental necessities 2023) [10]. This flexibility is especially useful in multicultural and hierarchical cultures such as those prevalent in Saudi Arabia where different levels of experience and cultural preconditions demand different leadership styles.

3.4. Theoretical Framework Path-Goal Leadership

Path-Goal Leadership Theory was initially defined by House in 1971 and perfected in 1996, but according to the theory, a good leader is the one that helps to increase the performance of the employees by clearly defining the objectives, eliminating hindrances and rewarding them in terms of the intended results (House, 1971; House, 1996; Pacia & Guevarra, 2023; Umuteme. 2024). The model, which is based on the expectancy theory, is that employees would be motivated more by the belief that their efforts would one day result in outcomes that they would cherish (House, 1971; Pacia & Guevarra, 2023; Umuteme. 2024). According to the theory, there are four main styles of leadership: directive, supportive, participative, and achievement-oriented; thus, a leader can change their approach depending on the traits of the staff, requirements of the task, and the situation in the environment (Murray et al., 2018) [19]; (Al-Shakhis and Banks-Santilli, 2023) [10].

The adaptability of the Path-Goal Leadership Theory is the strength of this theory especially in a complex healthcare environment. However, the critics claim that the theory might not be able to capture emotional and cultural aspects of leadership, which are particularly relevant in healthcare settings with emotional labour and high stress (Albalawi et al., 2020) [5]. Notwithstanding such shortcomings, despite the possible limitations, the Path-Goal Theory can still be an effective theoretical approach to healthcare leadership in Saudi Arabia, as it can allow the leaders to balance directive leadership with supportive and participative behaviours in reaction to organisational and cultural complexity. Such flexibility makes the theory an important place to build patient safety culture in Saudi healthcare organisations.

3.5. Regional Variations in Climate Impacts

Climate change impacts on agriculture exhibit strong regional variations reflecting differences in baseline climate conditions, crop types, farming systems, and adaptive capacity. Table 1 summarizes projected yield changes for major crops across different regions under moderate climate change scenarios.

Fig 1: Path Goal Leadership Theory Model 36

3.5. Conceptual Framework

The theoretical framework of the proposed study is based on the combination of the Path-Goal Leadership Theory and major aspects of patient safety culture to determine the effects of leadership behaviours on safe nursing practice. The framework assumes that leadership support works as a main antecedent that influences the safety-related behaviours of nurses by promoting psychological safety, communication, and effective teamwork in healthcare organisations. It is assumed that supportive and adaptive leadership behaviours would help to provide work environments where nurses are empowered to report errors and speak up and collaborate effectively, which effectively strengthen patient safety culture and reduce the risk of adverse events (Ismail & Khalid, 2022) [16]; (Albalawi et al., 2020) [5]. Based on the concepts of Path-Goal Leadership Theory, the framework suggests that leadership effectiveness in healthcare is achieved when leaders align their behaviours with staff needs, task demands, and organisational conditions to remove barriers and enhance motivation (House, 1971) [14]; (House, 1996) [15]; (Murray et al., 2018) [19]. In this regard, directive leadership provides clarity in complex clinical settings, supportive leadership enhances psychological safety, participative leadership encourages shared decision-making, and achievement-oriented leadership promotes high standards of performance and accountability (Pacia & Guevarra, 2023) [20]; (Umuteme, 2024) [22]. Within Saudi healthcare contexts, these adaptable leadership behaviours are particularly relevant due to multicultural workforce composition and hierarchical organisational structures that require flexible approaches to communication and decision-making (Al-Shakhis and Banks-Santilli, 2023) [10]. framework supposes that nurse managers can meet the objectives of patient safety by modifying their leadership style directive, supportive, participative, or achievement-oriented based on environmental requirements and team peculiarities. Leaders can support nurses in their safer clinical work and enhanced safety performance by setting expectations, eliminating obstacles, and offering suitable assistance. Characteristics of individuals and organisations, such as years of clinical practice, education level, and workplace environment, are a conceptualised moderating variable to determine the effects of nurses on the perception of leadership support and participation in patient safety culture initiatives (Mahsoon & Dolansky, 2021) [17].

The framework is based on the significance of adaptive leadership addressing hierarchical structures, multicultural dynamics of workforce, and communication issues in the environment of busy and culturally diverse healthcare in Saudi Arabia. Path-Goal Leadership Theory is a flexible and context-responsive theory, which allows nurse leaders to balance authority and support to address barriers to patient safety in organisations and cultures. Nurse leaders can improve patient safety culture through fostering psychological safety, openness in communication and teamwork activities and can help to provide safer and better-quality patient care in Saudi healthcare organisations (Albalawi et al., 2020) [5]; (Mahsoon & Dolansky, 2021) [17].

Fig 2: Conceptual Framework

4. Discussion

4.1. Mixed Themes and Theoretical Discussion

The analysed literature always confirms the belief that leadership is a crucial variable in patient safety culture, but there is yet no evident order on how this influence works. Significant evidence exists to reveal the behavioural Aspect of leadership, specifically, supportive leadership, as a major motivator of psychological safety, openness to communication, and safety incident reporting (Murray et al., 2018) [19]; (Mahsoon & Dolansky, 2021) [17]; (Rawas & Hashish, 2023) [21]. Supportive leadership has been linked to increased staff engagement, a better perception of safety culture, and more favorable safety-related outcomes in nurses in Saudi healthcare environments (Rawas & Hashish, 2023) [21]; (Alrasheeday et al., 2024) [9]. These results support the claim that leadership behaviours have an indirect impact on safety since they determine the relational and psychological climate in healthcare teams.

Conversely, a structural viewpoint focuses on the leadership in the design of systems, allocation of resources, and organisational control. In this perspective, the leaders can also promote patient safety through the clarification of roles, staffing shortages, standardisation of procedures, and elimination of operational barriers to safe practice which is closely related to Path-Goal Leadership Theory (House, 1971) [14]; (Almuntasheri & Almandeel, 2022) [8]. Nationwide empirical research in Saudi Arabia demonstrated that insufficient staffing, absence of reporting channels and channels, and low responsiveness to errors among management are closely linked with worse scores on the safety culture and a greater number of adverse and sentinel events (Binkheder et al., 2023) [13]; (Algethami et al., 2024) [6]. Such results indicate that leadership influence does not merely limit to interpersonal behaviours, that leadership involves structural and organisational roles that have a direct impact on patient safety.

Among the major discussions that come out of the literature is the issue of the balance between directive and participative leadership styles. In hierarchical healthcare, e.g., the Saudi Arabian one, directive leadership might squash nurse autonomy and discourage speaking up, whereas too participative might conflict with cultural norms of authority and control (Atikah et al., 2022) [12]; (Alaska & Alkutbe, 2023) [3]. A possible solution to this dilemma is the Path-Goal Leadership Theory, since it enables the leader to change the quality of leadership according to the requirements of the situation, the competence of the staff, and the limitations of the organisation, which helps overcome the gap between participative and directive leadership models (Murray et al., 2018) [19]; (Al-Shakhis and Banks-Santilli, 2023) [10]. This dynamic ability is especially applicable to Saudi healthcare settings, where power distances tend to be high, and there is multicultural dynamics of workforce.

Nurse leaders that possess strong leadership skills have been identified to have a positive impact on patient safety culture by sustaining a supportive work culture, guaranteeing the availability of the required resources, and enhancing team-based communication (Albalawi et al., 2020) [5]; (Rawas & Hashish, 2023) [21]. This leadership is beneficial to creating a culture where nurses place safety in their priorities and do not feel afraid to undertake safety behaviours, such as reporting errors and collaborating with other professionals (Alrasheeday et al., 2024) [9]; (Albaalharith and A’aqoulah, 2023) [4]. Nevertheless, cultural and language reasons continue to be the major barriers to psychological safety in Saudi healthcare facilities, especially among expatriate nurses (Aboufour & Subbarayalu, 2022) [1]. Although supportive leadership may help to reduce fear and foster communication, critics state that long-term patient safety culture changes cannot be achieved only due to the goodwill of individual leadership (Mahsoon & Dolansky, 2021) [17]; (Binkheder et al., 2023) [13].

4.2. Transformational and Path-Goal Perspective

Transformational leadership is a highly promoted leadership in the healthcare literature as it focuses on vision, inspiration, and intrinsic motivation. The improvement of the staff morale, innovation, and cultural change in the long term are commonly linked with this type of leadership (Mahsoon & Dolansky, 2021) [17]; (Al-Surimi et al., 2022) [11]. Nonetheless, it has been shown that transformational leadership might not be as flexible as situational and, in Saudi healthcare settings, will not be able to respond to short-term operational issues like workforce shortages, communication failures, or workload demands (Almuntasheri & Almandeel, 2022) [8]; (Algethami et al., 2024) [6]. In clinical settings that demand high pressure, the leader must make quick and directive decisions that ensure safety which might not be compliant with the participatory focus of the transformational leadership.

On the contrary, the Path-Goal Leadership Theory is more focused on the flexibility of leadership and responsiveness to the circumstances allowing the leaders to focus on the immediate safety issues and still promote the longer-term involvement of employees in the safety campaigns (House, 1971) [14]; (Murray et al., 2018) [19]; (Pacia & Guevarra, 2023) [20]; (Umuteme, 2024) [22]. The theory offers a practical approach to the management of structural and behavioural components of patient safety culture by giving leaders a chance to balance between directive and supportive, participative and achievement-oriented style of leadership. This flexibility can be beneficial especially in Saudi hospitals where the experience of the staff, the presence of diversity in culture, and the maturity of the organisation often vary (Alaska & Alkutbe, 2023) [3]; (Aljaffary et al., 2022) [7]. Instead of transformational leadership, Path-Goal Leadership Theory may be interpreted as complementary, providing operational instructions on leadership practice on a daily basis, especially among middle managers who serve as the linking factors between top leadership and frontline nurses 2023) [10]. Such a dual strategy would help healthcare organisations to work on both long-term cultural change and the need to solve immediate problems in safety and operations, thus contributing to the ongoing change in patient safety culture (Alrasheeday et al., 2024) [9]; (Binkheder et al., 2023) [13].

4.3. Theoretical Implications

The results of this review highlight the complexity of the idea of leadership impact on patient safety culture. Even though in most of the literature, transformational leadership is predominant, its assumptions, including low power distance and high levels of intrinsic motivation, might not necessarily be applicable in hierarchical healthcare systems such as those of Saudi Arabia (Atikah et al., 2022) [12]; (Alaska et al., 2023) [3]. Path-Goal Leadership Theory, in its turn, specifically considers the limitations of the environment, the difficulty of the task, and the differences in the motivation of staff members, which is why it is more flexible in terms of culturally and organisationally diverse contexts (Mahsoon & Dolansky, 2021) [17].

Path-Goal Leadership Theory has a high degree of flexibility; thus, leaders can adjust their leadership behaviours according to staff experience, workload, and demands of the situation, which closes a considerable gap between the idealised leadership models and the real-world healthcare practice 2023) [10]. This conceptual fit provides a more context-specific manner in which leadership can work in practicing patient safety culture within Saudi healthcare institutions, in which strict hierarchies and cultural orientations remain the defining factor in the leadership-staff interaction (Albalawi et al., 2020) [5]; (Aboufour & Subbarayalu, 2022) [1].

4.5. Practical Implications

Practically, the results of this review indicate that nurse leaders need to undergo specific training in adaptive leadership skills performance with the focus on identifying when to use directive, supportive, or participative leadership styles. The non-punitive error reporting, psychological safety, and shared decision-making should be specifically encouraged in healthcare policies as the elements of patient safety culture (Mahsoon & Dolansky, 2021) [17]; (Rawas & Hashish, 2023) [21]. Maintaining adequate staffing is a highly important leadership task because low staffing levels have been continuously associated with worse safety culture and more adverse events in Saudi hospitals (Binkheder et al., 2023) [13]; (Algethami et al., 2024) [6]. The leaders are also expected to foster open communication with the assistance of organized safety measures like safety huddles, feedback sessions, and multidisciplinary meetings along with frequent safety audits (Aljaffary et al., 2022) [7]; (Alrasheeday et al., 2024) [9]. As Saudi healthcare workforce is multicultural, leadership styles should be culturally aware and oriented to different degrees of experiences and communication patterns. Patient safety culture should be continuously monitored based on validated surveys and incident reporting systems so that gaps could be identified and further improvement efforts could be made (Alaska & Alkutbe, 2023) [3]; (Albaalharith and A’aqoulah, 2023) [4].

4.6. Loopholes in Research and Future Directions

Although there is strong evidence of the relationship between leadership and patient safety culture, there are still major gaps in research. The cross-sectional nature of most studies prevents causality and constrains the knowledge of the effect of leadership interventions on safety culture in the long term (Almuntasheri & Almandeel, 2022) [8]; (Alaska & Alkutbe, 2023) [3]. There are thus needs to assess whether patient safety outcomes could be sustained through leadership training based on the Path-Goal Leadership Theory. Further studies also need to focus on the mediating variable of middle managers as they are often the key variable between organisational leadership and the nursing personnel at the frontline. To have a more in-depth picture of the role of leadership in patient safety, additional variables, such as emotional intelligence, leader burnout, organisational constraints, and patient-level outcomes, should be included (Murray et al., 2018) [19]; (Al-Surimi et al., 2022) [11]. The filling of these gaps will help in coming up with leadership models that are theoretically sound and practical in the Saudi healthcare environment.

5. Conclusion

This research paper concludes that robust patient safety culture development and sustainability must depend on strong leadership support in the healthcare organisations, especially in complex and hierarchical organisations as is the case with the Kingdom of Saudi Arabia. Nurse leaders who can be flexible in their leadership styles and change their behaviours based on the requirements of their teams and organisational settings have higher chances of boosting communication, collaboration, and incident reporting, which leads to better patient safety outcomes. The inflexible models of leadership will not work in the culturally diverse healthcare setting; it needs adaptive and context-oriented leadership. The Path-Goal Leadership Theory provides a realistic and inclusive model, which harmonizes the leadership behaviours with staff requirements, situational needs, and cultural standards, to help the leaders to address behavioural and structural obstacles to patient safety. Nurse leaders can enhance patient safety culture and provide safer and higher-quality patient care in Saudi healthcare environments by providing psychological safety, encouraging non-punitive error reporting systems, sufficient staffing, and ongoing learning (Murray et al., 2018) [19]; (Mahsoon & Dolansky, 2021) [17]. • In hierarchical and multicultural health care settings, leadership flexibility is vital in the promotion of patient safety culture. • Rigid leadership models are not effective compared to adaptive leadership styles as described in the Path-Goal Leadership Theory. • The factors that must be encouraged to promote communication and organisational learning are psychological safety and non-punitive error reporting. • Proper staffing and allocation of resources is one of the key leadership roles in the provision of patient safety. • The programmes of leadership development must be based on cultural and organisational specifics of the Saudi healthcare institution.