Leadership Behavior Associations with Domains of Safety Culture, Engagement, and Health Care Worker Well-Being.

Journal Article (Journal Article)


Leadership is a key driver of health care worker well-being and engagement, and feedback is an essential leadership behavior. Methods for evaluating interaction norms of local leaders are not well developed. Moreover, associations between local leadership and related domains are poorly understood. This study sought to evaluate health care worker leadership behaviors in relation to burnout, safety culture, and engagement using the Local Leadership scale of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey.


The SCORE survey was administered to 31 Midwestern hospitals as part of a broad effort to measure care context, with domains including Local Leadership, Emotional Exhaustion/Burnout, Safety Climate, and Engagement. Mixed-effects hierarchical logistic regression was used to evaluate the relationships between local leadership scores and related domains, adjusted for role and work-setting characteristics.


Of the 23,853 distributed surveys, 16,797 (70.4%) were returned. Local leadership scores averaged 68.8 ± 29.1, with 7,338 (44.2%) reporting emotional exhaustion, 9,147 (55.9%) reporting concerning safety climate, 10,974 (68.4%) reporting concerning teamwork climate, 7,857 (47.5%) reporting high workload, and 3,436 (20.7%) reporting intentions to leave. Each 10-point increase in local leadership score was associated with odds ratios of 0.72 (95% confidence interval [CI] 0.71-0.73) for burnout, 0.48 (95% CI 0.47-0.49) for concerning safety climate, 0.64 (95% CI 0.63-0.66) for concerning teamwork climate, 0.90 (95% CI 0.89-0.92) for high workload, and 0.80 (95% CI 0.78-0.81) for intentions to leave, after adjustment for unit and provider characteristics.


Local leadership behaviors are readily measurable using a five-item scale and strongly associate with established domains of health care worker well-being, safety culture, and engagement.

Full Text

Duke Authors

Cited Authors

  • Tawfik, DS; Adair, KC; Palassof, S; Sexton, JB; Levoy, E; Frankel, A; Leonard, M; Proulx, J; Profit, J

Published Date

  • March 2023

Published In

Volume / Issue

  • 49 / 3

Start / End Page

  • 156 - 165

PubMed ID

  • 36658090

Pubmed Central ID

  • PMC9974844

Electronic International Standard Serial Number (EISSN)

  • 1938-131X

International Standard Serial Number (ISSN)

  • 1553-7250

Digital Object Identifier (DOI)

  • 10.1016/j.jcjq.2022.12.006


  • eng