Transformational and directive leadership in the operating room: Complementary effects under surgical complexity

Abstract

Leadership research has paid limited attention to how distinct leadership behaviours operate jointly under conditions of high complexity in high‐reliability settings. This study examines how transformational and directive leadership behaviours combine to influence team psychological safety and patient outcomes during complex surgical procedures. Drawing on situational strength theory and integrative leadership perspectives, we argue that the complementarity of people‐focused (transformational) and task‐focused (directive) leadership becomes especially functional when surgical complexity is high, enhancing team psychological safety and indirectly improving patient outcomes. We test these arguments using multi‐source, time‐sequenced data from 150 surgeries, including third‐party observations of intraoperative leadership behaviours, team reports of psychological safety, objective indicators of surgical errors and blood loss, and patient‐reported postoperative complications. Results show that under high surgical complexity, transformational and directive leadership interact to predict higher team psychological safety. In turn, psychological safety is associated with more observed surgical errors per hour but fewer and less severe post‐discharge complications. Transformational leadership shows no unconditional main effects; rather, its benefits emerge only when paired with directive leadership under high complexity. These findings highlight the importance of contextual boundary conditions and demonstrate how leadership combinations shape performance processes and outcomes in high‐reliability surgical environments.