Nurses’ attitude toward patients’ safety climate during COVID-19 pandemic: a cross-sectional study^†

Improving patient safety is a global necessity.¹ Employees’ understanding of the management, teamwork, work environment satisfaction, and workloads have significant impacts on the patient safety climate.² Patient safety reduced the unwanted complications of the therapeutic interventions by concentrating on preventive strategies.³ Annually, millions of patients around the world suffer from disability, injury, or even death caused by unsafe medical care, while about 50% of these complications are preventable.⁴

Rapid changes in the healthcare system require more attention to patient safety, which is necessary to provide efficient and high-quality health care. Patient safety is identified as a condition resulting from the modification of human behaviors or the design of a physical environment to reduce risks of unwanted events in hospitals.⁵ Thus, improving patient safety is a significant component of reducing medical errors and unwanted complications which is the common responsibility of all healthcare professionals.⁶

Recently, the COVID-19 pandemic, as a global concern, has created many challenges in the field of patient safety, especially in vulnerable groups, such as elderly people.⁷ Fear experienced by the general public due to the COVID-19 pandemic is likely enhanced by social isolation measures including quarantines, stay-at-home regulations, travel restrictions, and nonessential business closures.⁸ Providing safe and high-quality care should always be a fundamental goal of any healthcare system in the world, even in times of crisis such as natural disasters, wars, or epidemics. In this way, the effects of COVID-19 on healthcare workers and patient safety should be further investigated. One of the ways to gain insight into the patient’s safety situation is by evaluating the safety climate and reporting the incidents in hospitals.⁹ Active safety patient measures must continue even in pandemics. For this, we need various methods to evaluate and support patients’ safety during their hospitalization.¹⁰

We need to measure the safety climate in different units that provide the same services because it may be different from the general climate of that health organization.² Since nurses are the main players in patient safety and are mainly responsible for reporting complications, it is very important to evaluate nurses’ attitudes toward the safety climate. Identifying the strengths and weaknesses in the patient safety climate can help organizations in designing, implementing, and evaluating safety-related interventions.³

Safety climate plays a very important role in reducing safety-related events, such as medication errors. Also, it has been shown that rehospitalization is less reported in departments that have a more positive safety climate. It also improves the quality of nursing care.² Huang et al.’s¹¹ study suggested that hospital personnel with positive patient safety attitudes can help the organization reduce unwanted medical complications resulting from patient falls, medication errors, and employees’ absenteeism. According to Rigobello et al.,¹² job satisfaction and management understanding had respectively the greatest and the least impact on the safety climate in all studied professions. The safety climate may be evaluated as an indicator of the safety culture of medical-health centers’ state and the individual’s understanding of the attitude toward the organizational cultures.

Some studies evaluate the nurses’ attitude toward patients’ safety. However, rapid changes were observed in care delivery models during the COVID-19 pandemic, including increased workloads, working in an unfamiliar clinical setting, cancelation of routine services, and the need to treat patients with new diseases about which little is known. Working in these challenging conditions may affect the staff’s ability to provide a safe and effective care. The COVID-19 pandemic has placed unprecedented demands on healthcare systems all around the world. Hence, conducting this study during the COVID-19 pandemic is an innovative than other studies. On the other hand, there has been no systematic evaluation of the impact of the COVID-19 pandemic on patient safety. Although, a positive safety climate is associated with improved patient safety and, in turn, favorable therapeutic outcomes and patients’ satisfaction. This made authors enthusiastic to assess how COVID-19 and its related conditions change the attitude and performance of nurses toward patients’ safety. This study was conducted to evaluate the effects of COVID-19 pandemic on the safety climate with the nurses in Southeast Iran.

A total of 171 nurses participated in this study. The majority of them were female and married. Demographic characteristics of the included nurses are presented in Table 1.

According to the results of Table 2, the average safety climate of nurses in the present study was 2.98 ± 0.6 with a range of (1–4.59). The lowest and highest averages were respectively related to cumulative burnout and reporting errors and mistakes (3.47 ± 0.9–2.54 ± 0.76).

Based on the results of Table 3, the overall average of the safety climate among men was higher than women, although this value was not statistically significant (P = 0.06). Among the dimensions of the safety climate, only the educating nurses’ dimension between the 2 gender groups was statistically significant (P > 0.001) and there was no significant relationship between the overall average score of the safety climate and its dimensions in married and unmarried nurses with a second job. Only in the dimension of supervisor’s attitude (P > 0.01) and burnout (P > 0.001) a significant relationship was observed. Based on the employment status, it was significant only in the education dimension (P > 0.01). Also, in terms of the level of education, the overall score on safety climate (P > 0.01) and the supervisor’s attitude had a significant relationship (P > 0.01). The results showed that no significant relationship was found between the average score of the safety climate in other demographic variables, including the history of nursing errors and the type of work shift.

The Pearson correlation coefficient results between the safety climate dimensions (Table 4) show that there is a statistically significant relationship between all the factors.

Table 5 demonstrates the mean and standard deviation of nurses’ answers to the questions related to measuring their attitude toward patient safety climate.

Safety is a fundamental element of providing effective and high-quality care to patients. A safe climate prepares healthcare organizations to identify work problems and high-risk situations.¹⁴ In the current study, which was conducted to investigate the attitude of nurses toward the patient’s safety climate during the COVID-19 pandemic, the mean score of the safety climate was relatively favorable (moderate), which was in line with the findings of Yarmohammadi¹⁵ and Sarsangi¹³. It indicates that despite the special conditions during the COVID-19 pandemic, the attitude of nurses has not changed, which may be a positive point.

A high safety climate may result in more understanding and work commitment as well as creating a safe environment to report errors and mistakes. It should be noted that nurses play a very important role in improving the safety climate.^16,17 In the present study, similar to other studies, the mean score of reporting errors and mistakes was higher than other variables, and it seems that with greater interaction of managers, on-the-job training, and professional commitment, nurses are more inclined to report errors and mistakes.^13,15

Kim et al.¹⁸ also showed that internal and external factors such as nurses’ awareness, maintaining personal and professional reputation, sense of security, empathy, and managerial support are effective factors in reporting errors and mistakes and thus improving the safety climate. Also, Ghasemi et al.¹⁹ reported errors and mistakes, nurses’ training, and supervisor’s attitude as effective factors in safety participation. Among the effective factors in preventing errors and undesired conditions is the recognition of issues related to the nursing work environment and safety climate, which may reduce possible harm to the patients.²

Notably, a direct relationship exists between work environment problems and burnout.²⁰ In our study, the total burnout score was less than other safety climate dimensions, which is consistent with the results of Yarmohammadi¹⁵ and Ghiyasi.²¹ Monitoring systems should not only examine patients (complications and mortality) but also employees (job satisfaction and burnout), work environment (welfare, number of employees, educating of employees, working hours and amount check the admission and discharge of patients).²²

A high safety climate reduces burnout and job-related injuries, which can be achieved by taking into consideration the specific measures related to safety climates such as careful monitoring, timely provision of support and solutions, and nurses’ support in reporting and responding to errors and mistakes.

A safe climate provides an environment for nurses to learn and feel safe. Quality patient care requires enhancing job satisfaction, management leadership skills, and teamwork. Currently, the working conditions of nurses and the safety climate need improvement in most health organizations. Building a learning and nonpunitive work environment and developing effective communications among health staff as well as on-the-job training programs and pairing experienced nurses with less experienced ones are factors that should be considered in the plans of managers for creating a safe climate.^23,24

By improving the leadership skills of managers and their commitment to safety as well as holding meetings to share experiences and provide feedback, creating a culture of learning from errors and mistakes, using measures to remove organizational obstacles, and increasing the awareness of nurses, the safety climate can be improved.²⁵ However, improving the safety climate sometimes does not require large investments; with some changes in the behavior of the management and care teams, the safety climate can be easily improved. When health workers, including nurses, are equipped with the knowledge of safety attitudes, a safe and high-quality nursing care can be provided to patients by health organizations.²⁶

In our study, male supervisors with master’s degrees and stable employment status paid more attention to the safety climate. It seems that experienced nurses in higher and secured positions have a greater desire to comply with safety and share related knowledge and experiences. Cooperation among staff in a safe climate can lead to greater effectiveness in organizations.^23,27 More future research on the effects of gender on the safety climate and its related factors seems necessary.

In the present study, the score of nurses’ safety climate was average. Since the safety climate is one of the important factors in improving the quality of patient care, nursing managers should pay more attention to its related factors, such as job burnout and continuous training of employees and supervisors, communication skills, and creating a safe and nonpunitive climate for reporting errors and mistakes.

The small sample size, localization of the study, and the exclusion of some samples for not answering all questions in the questionnaire were the limitations of the current research. Therefore, it is recommended to conduct research with a larger sample size in a wider geographical area.