Formal vs. informal authority: A mixed-methods study of nursing leadership and patient safety in Palestinian...

In fragile healthcare systems such as Palestine's, nursing leadership is critical for patient safety, yet its nature and influence remain poorly understood.

This study aimed to analyze the forms and extent of nursing leadership authority-both formal and informal-and its impact on patient safety in Palestinian hospitals.

A mixed-methods, convergent cross-sectional design was employed across three governmental hospitals in the West Bank. Data were collected via surveys (n=123 nurses), semi-structured interviews (n=15 nursing leaders), and document analysis. Quantitative data were analyzed using descriptive statistics, multiple regression, and mediation analysis; qualitative data were analyzed thematically.

Nursing leaders possessed moderate to high operational authority (e.g., clinical supervision, staff scheduling) but were systematically excluded from strategic and financial decisions. Regression analysis revealed that strategic authority (β = 0.52, p < .001) was a stronger predictor of safety adherence than operational authority. Informal strategies (e.g., persuasion, coalition-building) mediated the relationship between low formal authority and safety compliance. Document analysis confirmed a formal gap in governance structures, and qualitative findings highlighted a "Vicious Cycle of Disempowerment" rooted in hierarchical, physician-dominated cultures and resource constraints.

Strategic disempowerment of nursing leaders creates an unsustainable reliance on informal influence, which carries high emotional labor and systemic fragility. To sustainably improve patient safety, structural reforms-such as establishing executive nursing roles (e.g., Chief Nursing Officers) and integrating nursing leadership into hospital governance-are urgently needed in Palestine and similar constrained settings.