Understanding how leadership styles influence attitudes to error disclosure in veterinary practice

THE causes and classifications of medical error in human healthcare have been studied for many years, resulting in a comprehensive understanding of the types of errors that occur most frequently and their contributing factors.1 This knowledge has informed the development of targeted interventions aimed at preventing and mitigating such errors. Veterinarians, like their counterparts in human medicine, are not immune to error. However, the veterinary profession currently lacks comprehensive morbidity and mortality data, established frameworks for classifying errors and a mature understanding of the factors that contribute to or facilitate such mistakes. The few comparable incidence studies within the veterinary literature are largely confined to measures of perianaesthetic mortality.2 While valuable, these studies do not attempt to determine the contribution of human error and lack the integration of human factors and systems-based perspectives that underpin modern approaches to patient safety in human medicine.3, 4 Fear and a lack of belief that incident reporting will bring about meaningful change are frequently cited as the two most significant barriers to reporting medical errors in human healthcare settings. These factors inhibit both individual and organisational learning, undermining efforts to prevent error recurrence.5, 6 Similar attitudes toward error have also been identified within the veterinary literature. For example, while a Delphi study of veterinary anaesthetists found universal acknowledgement that mistakes and near misses occur, there was a pervasive fear of punitive consequences and a recognition that ‘nobody speaks of them’.7 Such cultural and psychological barriers highlight the need for strategies that encourage open discussion of errors and foster a learning-focused, non-punitive environment within veterinary practice. Within the human medical sector, errors are now widely understood to arise from the complex interaction between the cognitive limitations of individuals and the environmental or systemic factors that influence their decisions.1 This systems-based perspective recognises that errors often reflect weaknesses within organisational structures, processes or cultures rather than solely individual shortcomings. Consequently, effective leadership has been identified as a critical component in promoting patient safety, particularly in the implementation and sustainability of safety-focused interventions. It is this issue of the influence of leadership styles on safety culture that is addressed in a recent study by Santos and colleagues,8 summarised on p 370 of this issue of Vet Record. This study specifically examines the impact of ‘humble leadership’ on factors such as psychological safety and safety climate, and how these may influence attitudes toward error disclosure. In this context, humble leadership involves leaders being open about their own limitations, emphasising the abilities and contributions of their team and encouraging continuous learning, thereby supporting staff empowerment and enhancing psychological safety (Fig 1).9 Santos and colleagues' study population comprised a convenience sample of participants representing a diverse range of roles and levels within Australian veterinary practices.8 Participants included junior and senior veterinarians, receptionists, practice managers and veterinary nurses of all or unspecified genders, working in either part-time or full-time roles across a wide range of practice types. The survey that participants were asked to complete employed previously validated Likert scales to assess each factor of interest.8 For humble leadership, the items were framed for respondents to assess the leadership behaviours of their immediate supervisor or manager. Psychological safety was considered in the context of the respondents' current workplace, while safety climate focused specifically on error-related aspects. Meanwhile, attitudes toward error disclosure were evaluated using a tool specifically designed to capture professionals' perceptions and concerns regarding the disclosure of errors, particularly to clients.10 Consistent with previous research, hospital directors tended to rate their own humility higher than frontline veterinarians and veterinary nurses tended to rate hospital directors' humility.8 This discrepancy likely stems from a gap between leaders' intentions and how their behaviours are actually perceived by their teams. Psychological safety also varied across hierarchical levels, with directors reporting higher levels than frontline veterinarians and veterinary nurses and veterinarians reporting higher levels than veterinary nurses.8 These differences are likely influenced by the perceived authority associated with these roles within the organisational structure. Additionally, gender played a role in psychological safety, with women reporting lower levels than men8 – a trend that is well-documented within the existing literature.11, 12 While safety climate reflects a team's immediate perceptions and attitudes, safety culture encompasses the deeper organisational norms and values that shape those perceptions over time. Given the structured nature and formal safety protocols of veterinary teaching hospitals, one might expect them to score highest in terms of safety culture. However, mixed and small animal general practice outperformed them.8 This finding may be attributed to the closer-knit nature of smaller teams, which often fosters stronger communication and collaboration. However, somewhat surprisingly, safety climate scores were not significantly correlated with attitudes to error disclosure in Santos and colleagues' study.8 Finally, mirroring the findings on psychological safety, men and individuals in positions of authority expressed more favourable attitudes toward error disclosure.8 Whether this stems from greater confidence or a stronger sense of support remains uncertain, but the trend is consistent with existing literature.13 In summary, Santos and colleagues' study demonstrates that humble leadership plays a vital role in cultivating a positive safety culture – one that encourages open dialogue and ultimately enhances patient safety. However, while humility appears pivotal, leadership is rarely expressed through a single style in practice, and a skillfully blended approach that is inclusive and responsive to all staff members will likely be necessary to truly achieve a positive safety culture.