Evaluation of patient safety culture as perceived by nurses during the COVID-19 pandemic

Millions of patients suffer from sickness, accidents, or death each year due to unsafe medical practices. Worldwide, it is believed that 4 in 10 clients are injured in primary care and outpatient settings. One in every 10 patients in developed countries is predicted to be harmed during hospitalization. Each year, 134 million adverse incidents happen in hospitals in low- and middle-income countries (LMICs), resulting in 2.6 million fatalities.^1–3

Hospital safety culture evaluation has been used as a managerial tool in countries all over the world, with backing from health authorities and administrators. The evaluation of culture can be used for a variety of purposes, including increasing staff knowledge of the importance of patient safety; assessing current conditions of the organisation; highlighting the positive aspects of safety culture as well as development opportunities; analyzing the evolution of safety culture over time; assessing the effect of patient safety strategies and initiatives on safety culture; and making parallels between them within healthcare facilities.⁴

It is available to experts all around the world who are interested in evaluating their hospital’s safety culture. Hundreds of hospitals in the United States and other developed and poor nations utilize it. Over 60 countries have researched using this tool by 2015, and it is available in 30 versions and is backed up by research on cross-cultural adaptation.⁵

Patient safety culture (PSC) has become an important component of healthcare organizations’ efforts to minimize patient harm and provide safe, high-quality treatment. The term “patient safety culture” refers to a subset of the corporate culture. Beliefs, ideas, attitudes, opinions, norms, processes, skills, and behavioral patterns of individuals and groups all play a role in determining a health organization’s commitment to patient safety management.⁶

The IOM has emphasized the creation of basic patient safety initiatives to strengthen safety culture and create safe health systems; for example, reporting and analyzing safety incidents using non-punitive methodologies, establishing multidisciplinary team training safety programs, and using firm safety concepts, equipment, materials and work methods that are standardized and streamlined. The IOM, on the other hand, has stated that the most challenging aspects of achieving a safety culture are the cultural change that happens and the frequent blame put on people for a system approach.^6,7

An Albanian study indicated that 6 organizational factors could influence the safety culture of healthcare workers. These factors included managerial support, teamwork climate, communications, job satisfaction, and working conditions. Finally, there was the stress recognition component and how stressors affect work. Communication failures and ineffectiveness are blamed for a large percentage of mistakes in healthcare.⁸

Research in the Middle East, including Palestine, and Egypt, indicated that there are some areas of weaknesses like communication and teamwork, especially across hospital units and professions, which lower the PSC.^9,10

According to a Saudi Arabian study, variables contributing to the PSC include blame culture, incompetent leadership, poor communication, and workload/inadequate personnel. In contrast, “strength” characteristics influencing a strong PSC include realistic management expectations and supportive actions encouraging patient safety, good unit collaboration, and organizational attitudes toward learning/continuous improvement.¹¹ Furthermore, Elmontsri (2017) claimed that blame culture and poor communication were typical variables related to a low PSC in Saudi Arabia. Fear of being accused was cited as a major impediment to nurses in Saudi Arabia reporting incidents and prescription mistakes.^12,13

Nurses play a critical role in patient safety because they are the frontline advocates who implement safety and quality programs in the clinical setting. Under the practitioner’s supervision, however, patient safety-related errors and injuries are nevertheless common. Although there is a wealth of information on PSC in various areas of the world, there is little research on the subject in the Arab world, particularly in Saudi Arabia. As a result, studies on this issue in Saudi Arabian hospitals are required to clearly depict the existing PSC in the Kingdom. Scholars also propose assessing safety culture in the clinical setting regularly to discover opportunities for improvement. As a result, the goal of this study was to determine the degree of PSC from the perspective of nurses during the COVID-19 epidemic.

Registered nurses working at EJGH and KFGH who offer direct care and have at least 1 year of experience were included in the study (n = 315). There was a 100% response rate. Table 1 shows the frequency and percentage of sociodemographic characteristics of the 2 hospitals in the study sample, which consisted of n = 85 from KFGH (27%) and n = 230 from EJGH (73%) participants. Only 10.2% of the nurses were >40 years old, with slightly more than half of the nurses (53.3%) being between the ages of 30 years and 40 years. The majority (94.9%) were female, with Saudi nurses accounting for slightly more than two-thirds (68.9%). When it came to marital status, over half of the nurses (58.4%) were married, with only 6.3% being divorced. Furthermore, just 62.5% of respondents had a bachelor’s degree, in addition to only 3.8% having a master’s degree or above. A little >3-quarters of respondents (77.4%) had >5 years of experience, whereas just 22.6% of nurses had 1–5 years of experience. In addition, one-third (34%) worked in intensive care units, whereas just 2.5% worked in isolation. In terms of the hospital, just over a third of the nurses (27%) worked at King Fahad General Hospital, while almost 3-quarters (73.0%) worked at EJGH.

The nurses’ responses regarding PSC statements or items (overall safety perception, number of reported incidents, and handoffs and transitions) are clarified in Table 2. When it comes to general safety perceptions, the nurses strongly agreed with the statement “getting more work done never means compromising patient safety,” with the highest weighted mean (4.37 ± 0.73), while the lowest weighted mean was 3.61 ± 0.93, showing that nurses agreed with the item “here, we have a very low serious error rate just by chance.” As indicated in the composite of the rate of incidents stated, the ultimate weighted mean was 4.23 ± 0.91 for the statement “when a mistake is made that could injure the patient but does not”. Conversely, the lowest weighted mean was 3.61 ± 0.93, which indicated that nurses agreed with the statement “when a mistake is made but has no risk of injury to the patient.”

In the composite of handoffs and transitions, the highest weighted mean was 4.19 ± 0.79, which indicated that nurses agreed with the statement “while moving clients through one department to a different unit, things ‘slip between the cracks,’” while the lowest weighted mean was 3.42 ± 1.37, indicating that nurses agreed with the statement “problems frequently arise during information flow around hospital departments.”

PSC was rated as medium overall, with a weighted mean of 2.88 ± 0.76 and a relative weight of 57.57%. Also, all PSC composites were rated on a scale from medium to high, except for the composite of organizational learning, which had a low level. The highest weighted mean for the average of people’s overall safety perceptions was 4.12 ± 0.48, with a relative weight of 85.43%. In contrast, the lowest mean was for the composite of organizational learning (2.16 ± 1.16) with a relative weight of 43.21% (Table 3).

The frequency and percentages for the nurses regarding the levels of PSC are indicated in Table 4. The nurses’ responses reveal that 42.54% of them had a weighted mean from 2.61 to <3.40, which means they had a medium level of PSC. In comparison, the lowest percentage, 5.40%, had a weighted mean from 1 to <1.80, implying a very low PSC level.

The relationship between sociodemographic variables and levels of PSC was investigated using the t-test and one-way ANOVA test, as indicated in Table 5. The association is statistically significant when P ≤ 0.05. The findings revealed a statistically significant correlation between respondent nationality (t = −4.399, P = 0.000), experience in years (F = 3.760, P = 0.024), nurses age (F = 7.917, P = 0.000), and hospital (t = −0.401, P = 0.689).

EJGH, East Jeddah General Hospital; KFGH, King Fahd General Hospital; PSC, patient safety culture.

These results showed that Saudi nurses had higher levels of PSC (3.15 ± 0.74) than non-Saudi nurses (2.76 ± 0.73). Nurses who were ≥40 years old had higher PSC levels (3.32 ± 0.52) than others. Likewise, nurses with work experience of 1 year to <5 years had higher levels of PSC (2.98 ± 0.75) than others. The nurses who worked at EJGH had higher levels of PSC (2.89 ± 0.76) than the nurses who worked at King Fahad General Hospital.

However, the PSC level was not significantly associated with nurses’ gender (t = −0.130, P = 0.897), marital status (F = 0.644, P = 0.526), educational level (F = 2.767, P = 0.064), and working unit (F = 1.865, P = 0.066).

This research aimed to investigate nurses regarding the levels of PSC during the COVID-19 pandemic. Based on the findings of this research, PSC was rated as medium overall. Also, all PSC composites ranged from a medium to a high level, except for the composite of organizational learning, which had a low level. These findings contradict those of a previous study in which 784 general practitioners (GPs) and triage nurses were utilized in a descriptive cross-sectional design study in the Netherlands to assess PSC in Dutch primary care outside of working hours. The study found a higher score in all PSC factors of triage nurses than GPs, particularly on perceptions of management and communication openness. Also, it was reported that healthcare professionals’ perspectives of PSC are influenced by their practice experience and age. However, the Dutch PSC is seen highly by healthcare practitioners.¹⁹ Nevertheless, in Brazil, a study reported the opposite result, revealing a negative PSC among healthcare providers, mainly managerial perception.²⁰ Furthermore, a study conducted a descriptive cross-section of 250 Egyptian healthcare providers to identify baseline perceptions and attitudes toward patient safety across healthcare disciplines. Based on the results, there was an overall safety culture-positive perception.¹⁰

Moreover, A descriptive cross-sectional survey was carried out to examine the PSC of different healthcare professionals from various countries employed in a Saudi Arabian medical facility’s adult oncology department. The data from 127 healthcare professionals were analyzed. Based on the results, PSC can be considered to be significantly more positive among physicians than among nurses and pharmacists. Additionally, this study assumed a shared understanding of patient safety among all healthcare professionals.²¹

Despite this, a systematic review based on the HSOPSC results attempted to take a closer look at PSC in Arab nations. As a result of this study, they realized that patient safety must be promoted as a strategy in the Arab world.¹²

Another study looked at the culture of patient safety in a large Riyadh-based multi-site healthcare center. They compared it to a previous assessment from 2012 as well as regional and international studies. Furthermore, the researcher looked at the correlation between PSC predictions along with client outcomes while taking demographic factors and hospital size into account. In a descriptive cross-sectional design of 2592 healthcare providers, the Medical City still has areas that need further improvement. However, there was significant progress in many components of the culture of patient safety.²²

The relationship between sociodemographic variables and the levels of PSC was investigated using the t-test and one-way ANOVA test, as indicated in Table 5. The association is statistically significant when P ≤ 0.05. The findings revealed a statistically significant correlation between respondents’ nationality (t = −4.399, P = 0.000), experience in years (F = 3.760, P = 0.024), nurses’ age (F = 7.917, P = 0.000), and hospital (t = −0.401, P = 0.689).

Regarding the composite of communication and feedback on faults, the ultimate weighted mean was 3.89 ± 0.87, which showed that nurses agreed with the statement “we’ll talk about how to avoid making the same mistakes in this unit,” while the lowest weighted mean was 1.76 ± 1.13, indicating that nurses strongly disagreed with the statement “we receive comments on modifications made in response to event reports.” In the composite of non-punitive retaliation for errors, the highest weighted mean was 4.19 ± 0.79, which indicated that nurses agreed with the statement “employees believe their mistakes are being used against them,” while the lowest weighted mean was 3.45 ± 1.37, showing that nurses agreed with the statement “employees are concerned that any mistakes they make will be recorded in their personal file.”

A variety of medical mistakes or adverse occurrences are to blame for this issue. Most medical mistakes that are harmful are diagnosis, prescription, the use of medicines, unsafe surgical care procedures, and unsafe injection practices. These errors led to the broader recognition of the importance of patient safety, the integration of patient safety methods into healthcare organizations’ strategic plans, and the increasing the database of research in this area to prevent and reduce risks, mistakes, and harm that can occur to patients during the provision of healthcare. Medical errors result in longer hospital stays, higher lawsuit expenses, healthcare-associated illnesses, lost earnings, disabilities, and increased healthcare expenditures. However, medical mistakes are preventable, enhancing all aspects of patient safety.^3,23

There has been a lot of research done on assessing PSC. The literature utilizes 2 of the most widely applied methods created by the AHRQ to assess the safety culture. The safety attitude questionnaire (SAQ) and the HSOPSC are 2 of these instruments. The SAQ is regarded as the most effective instrument in this field, while the HSOPSC examined PSC at a particular hospital in a specific location. As a result, each institution should be treated as a different location for administering surveys and providing hospital-specific feedback.^15,24

The nurses in this study had a medium overall PSC level, and all PSC composites ranged from a medium to a high level, except organizational learning, which had a low level. In addition, the findings showed that there is a significant relationship between PSC levels, nurses’ nationalities, experience in years, and the hospital.