gms | German Medical Science

16. Deutscher Kongress für Versorgungsforschung

Deutsches Netzwerk Versorgungsforschung e. V.

4. - 6. Oktober 2017, Berlin

Agreeing on What Matters – How team cooperative norms mediate the effect of leader goal alignment on team safety climate in neonatal intensive care units

Meeting Abstract

  • Hendrik Hillen - Universität zu Köln, Köln, Germany
  • Michael Wittland - Hochschule Hannover (HsH), Hannover, Germany
  • Hendrik Wilhelm - Universität zu Köln, Köln, Germany
  • Ludwig Kuntz - Universität zu Köln, Köln, Germany
  • Kyriakos Martakis - Universitätsklinikum Köln, Köln, Germany
  • Bernhard Roth - Universitätsklinikum Köln, Köln, Germany
  • Nadine Scholten - Humanwissenschaftliche Fakultät und Medizinische Fakultät der Universität zu Köln, Köln, Germany

16. Deutscher Kongress für Versorgungsforschung (DKVF). Berlin, 04.-06.10.2017. Düsseldorf: German Medical Science GMS Publishing House; 2017. DocV170

doi: 10.3205/17dkvf019, urn:nbn:de:0183-17dkvf0199

Veröffentlicht: 26. September 2017

© 2017 Hillen et al.
Dieser Artikel ist ein Open-Access-Artikel und steht unter den Lizenzbedingungen der Creative Commons Attribution 4.0 License (Namensnennung). Lizenz-Angaben siehe



Background: Premature infants in Neonatal Intensive Care Units (NICUs) are prone to acquiring adverse health conditions troughout procedures and treatments delivered by the medical team. Although adverse conditions appear in daily NICU practice, research found them to be largely preventable [1]. Safety Climate is an effective means to prevent unintended harm and leads to better safety outcomes [2]. Surprisingly little research has focused on how medical and nursing leadership of NICUs jointly affects the NICU safety climate. This lack of research is surprising, because NICU leadership and staff cover different professional backgrounds, predominantly belonging to the physician or nursing profession. The different professional identities working in NICUs may hamper safety-relevant team behavior, because they imply different professional norms, values and expectations [3]. Since leaders influence working conditions [2], NICU leadership could overcome these differences, and support the development of cooperative norms that benefit team safety climate in NICUs. This however, presumes that NICU medical and nursing leadership agrees on goals for the NICU. Specifically, goal alignment might provide a common framework and thereby a basis for shared actions [4] that serves as an example to NICU staff, thus thwarting day-to-day conflicts between NICU staff. Such cooperative norms should provide the ground for safety climate and improved patient outcomes.

Research Question:

Is NICU leadership perceived goal alignment positively associated with unit safety climate as perceived by the unit staff?
Is the relationship between NICU leadership perceived goal alignment and safety climate mediated by team cooperative norms?

Methods: Our analyses draw on survey data collected in Level 1 and Level 2 NICUs in Germany between September 2015 and August 2016. We approached the two most relevant professions (i.e., physicians and nurses) at the leadership and the staff level. Our sample contains data on 62 NICUs, each with a complete leadership dyad (i.e., the leading nurse and the leading physician). On the staff level, we have data on 1.081 nurses and 405 physicians. Because our dependent variable is range-limited (0 – 100), we tested our hypotheses using a fractional response regression model. We controlled for alternative explanations, such as NICU characteristics and staff demographics. Additional robustness checks were conducted.

Results: Our results provide support for the hypothesis that NICU leadership perceived goal alignment positively affects NICU safety climate (p < 0.01). The proposed mediation was tested by regressing safety climate on shared goals at the dyad level, with cooperative norms included as predictor. Results confirmed that the association between shared goals among leaders and NICU safety climate was fully mediated by cooperative norms among the nursing and medical staff (p < 0.001).

Discussion: Our results suggest NICU leadership perceived goal alignment could present an important explanation for team cooperative norms, and safety climate. Particularly, interprofessional agreement on goals among leaders could be beneficial for cooperation and eventually overcoming boundaries between nursing and medical staff, which in turn enable open communication and learning. Since discrepant attitudes towards teamwork and cooperation among nurses and physicians seem to persist in many health care settings, our research suggests that hospital leadership should compose department leadership also depending on the individual leaders’ goal alignment. Because our study suffers from the common limitation of survey research, we would welcome future research that tests the importance of the different mechanisms (e.g. interprofessional role models) linking NICU leadership goal alignment to staff levels.

Practical Implications: Our study is a step towards modelling research around day-to-day delivery of medical care. Because we uncover effects related to the NICU leadership dyad, we hope to provide new ideas on how practitioners can improve the day-to-day working conditions in NICUs or other departments characterized by complex interprofessional work.


Kugelman A, et al. Iatrogenesis in neonatal intensive care units: observational and interventional, prospective, multicenter study. Pediatrics. 2008;122(3):550-555.
McFadden KL, Stock GN, Gowen III CR. Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety. Health Care Manage R. 2015; 40(1):24-34.
Williams KY, O’Reilly III CA. A review of 40 years of research. Res Organ Behav. 1998;20:77-140.
Kristof‐Brown AL, Zimmerman RD, Johnson EC. Consequences of Individual’s fit at work: A meta-analysis of Person-Job, Person-Organization, Person-Group, and Person-Supervisor fit. Pers Psychol. 2005;58(2):281-342.