Patient Safety Climate and Worker Safety Behaviours

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Patient safety climate and worker safety behaviours in acute hospitals in Scotland

Cakil Agnew, Rhona Flin ⁎, Kathryn Mearns

Industrial Psychology Research Centre, School of Psychology, University of Aberdeen, Aberdeen AB24 3UB, Scotland, UK

a b s t r a c ta r t i c l e i n f o

Article history:

Received 17 May 2012

Received in revised form 13 December 2012

Accepted 24 January 2013

Available online 11 February 2013

Keywords:

Safety climate

Safety compliance

Safety participation

Worker and patient injuries

Objectives: To obtain a measure of hospital safety climate from a sample of National Health Service (NHS)

acute hospitals in Scotland and to test whether these scores were associated with worker safety behaviors,

and patient and worker injuries. Methods: Data were from 1,866 NHS clinical staff in six Scottish acute

hospitals. A Scottish Hospital Safety Questionnaire measured hospital safety climate (Hospital Survey on

Patient Safety Culture), worker safety behaviors, and worker and patient injuries. The associations between

the hospital safety climate scores and the outcome measures (safety behaviors, worker and patient injury

rates) were examined. Results: Hospital safety climate scores were signicantly correlated with clinical

workers’ safety behavior and patient and worker injury measures, although the effect sizes were smaller

for the latter. Regression analyses revealed that perceptions of staf ng levels and managerial commitment

were signicant predictors for all the safety outcome measures. Both patient-specic and more generic safety

climate items were found to have signicant impacts on safety outcome measures. Conclusion: This study

demonstrated the inuences of different aspects of hospital safety climate on both patient and worker safety

outcomes. Moreover, it has been shown that in a hospital setting, a safety climate supporting safer patient

care would also help to ensure worker safety. Impact on industry: The Scottish Hospital Safety Questionnaire

has proved to be a usable method of measuring both hospital safety climate as well as patient and worker

safety outcomes.

© 2013 National Safety Council and Elsevier Ltd. All rights reserved.

1. Background

1.1. Patient safety in Scotland

Recent research in healthcare has tended to focus on iatrogenic

injury to hospital patients but signicant numbers of healthcare

staff can also experience workplace injuries. In 2010–2011, 1,649

major injuries and 9,741over-3-day injuries to UK healthcare

employees were reported (HSE, n.d.). A National Health Service

(NHS) staff survey revealed that 19% of staff reported seeing at least

one error or incident that could have hurt staff, and 25% of staff had

witnessed at least one error or near miss that could have hurt patients

(Healthcare Commission, 2007).

Scotland has an NHS, similar to that in England, with rates of

adverse events for patients in acute hospitals of approximately 8%

(Williams et al., 2008), comparable to other countries. In 2007, the

Health Department launched a Scottish Patient Safety Alliance, a

national initiative to improve patient safety in acute hospitals, with

the aim of reducing adverse events by 30% and deaths by 15% in a

four year period, along with clinical targets (SPSP, n.d.) This was one

of the rst initiatives targeting patient safety on a national scale and a

key objective was, ‘to drive a change in the safety culture in NHS orga-

nizations’ (SPSP, n.d.). Safety culture can be dened as “the product of

individual and group values, attitudes, perceptions, competencies and

patterns of behavior that determine the commitment to, and the style

and prociency of, an organization's health and safety management”

(Schein, 2004) with safety climate as a surface manifestation (Flin,

Mearns, O'Connor, & Bryden, 2000), a ‘snapshot’ of the prevailing safety

culture, typically measured by questionnaires.

1.2. Patient safety climate and safety outcomes

Using questionnaire measures, safety climate has been shown to

be related to safety outcomes in a number of industrial settings

(Clarke, 2006; Christian, Bradley, Wallace, & Burke, 2009; Neal &

Grif n, 2006; Neal, Grif n, & Hart, 2000). For example, a meta-

analysis (Christian et al., 2009) demonstrated a link between better

safety climate scores and lower archival worker accident data and

self-reported accident/injuries.

Several safety climate instruments have been developed to

assess hospital staff's perceptions of workplace safety (for reviews see

Colla, Bracken, Kinney, & Weeks, 2005; Flin, Burns, Mearns, Yule, &

Robertson, 2006; Jackson, Sarac, & Flin, 2010). Management commit-

ment to safety has been identied as a dominant theme in safety

climate measurement within the industrial safety literature (Flin et al.,

2000). Healthcare organizationsalso includethis factor in safetyclimate

assessment, using items focusing on management's support for

the safety of workers (Gershon, Karkashian, Grosch, 2000; Gershon,

Journal of Safety Research 45 (2013) 95–101

⁎ Corresponding author. Tel.: +44 1224 273212.

E-mail address: [email protected] (R. Flin).

0022-4375/$ – see front matter © 2013 National Safety Council and Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.jsr.2013.01.008

Contents lists available at SciVerse ScienceDirect

Journal of Safety Research

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http://dx.doi.org/10.1016/j.jsr.2013.01.008http://dx.doi.org/10.1016/j.jsr.2013.01.008http://dx.doi.org/10.1016/j.jsr.2013.01.008mailto:[email protected]:[email protected]:[email protected]://dx.doi.org/10.1016/j.jsr.2013.01.008http://www.sciencedirect.com/science/journal/00224375http://www.sciencedirect.com/science/journal/00224375http://dx.doi.org/10.1016/j.jsr.2013.01.008mailto:[email protected]://dx.doi.org/10.1016/j.jsr.2013.01.008


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Vlahov, Felknor, 1995; Naveh, Katz-Navon, & Stern, 2005; Neal et al.,

2000; Smith et al., 2010) or for the safety of patients (Sorra & Nieva,

2006). Huang et al. (2010) found an association, across 30 ICU units,

where lower safety climate scores related to increased length of stay

for patients, and less favorable perceptions of management by staff

were related to higher patient mortality rates. However in a survey of

staff in 30 hospitals in the USA, no evidence of relationships between

senior management's engagement or unit managers’ support for pa-

tient safety and patient safety indicators (e.g. hospital discharge data)were observed (Rosen, Singer, Zhao, 2010).

Zohar, Livne, Tenne-Gazit, Admi, and Donchin (2007) assessed 955

Israeli hospital nurses’ safety behaviors through observational tech-

niques, and showed both unit and hospital level safety climates (using

bothgenericand patientfocused items) were predictors of workers’ safe-

ty behaviors. Similarly, a study of 789 hospital workers in the USA, found

thatwhen senior managementsupport for worker safety, safety feedback

and training were perceived favorably, workers experienced fewer blood

andbodyuid exposureincidents (Gershon et al., 2000).In Japan,a more

positive safety climate was associated with safety of workers such as

reduced needlestick and sharp injuries (Smith et al., 2010).

Thus the inuence of hospital safety climate on patient and work-

er safety outcomes is not entirely clear, even though they appear to

have common causal factors (Flin, 2007). Staff perceptions of generic

safety climate (without a specic focus on patient care) were related

to treatment errors in one Israeli acute hospital (Naveh et al., 2005).

Few studies have measured both patient iatrogenic injuries and

staff occupational injuries, but common associations are beginning

to emerge. Hofmann and Mark (2006) in a study of 1127 nurses

from 42 hospitals in the USA found that safety climate predicted

both patient outcomes (medication errors, urinary tract infections)

and nurse outcomes (back injuries, needlestick). The complexity of

patient conditions exerted a moderating effect. More recently,

Taylor et al. (2012) studied 723 nurses from 29 units in one hospital

and found that two safety climate factors were associated with

nurse injuries and patient adverse events (decubitus ulcer). A staf ng

factor (turnover) was found to be a particular risk factor. Therefore, it

appears that when the safety climate is associated with safer patient

care, it may also be associated with better safety for workers.

1.3. Aim

The rst aim of this study was to test which dimensions of hospital

safety climate were associated with patient and worker safety outcome

measures for a Scottish sample. Three outcome measures were used:

(a) clinical workers’ self-reported safety behaviors, specically, safety

compliance and participation; (b) self-reportsof worker errors affecting

patients (i.e. patient injury); and (c) self reports of worker injuries.

Positive associations between safety climate scores and self-reports of

desirable workers’ safety behaviors were expected, as well as negative

associations between safety climate scales and both worker and patient

injury rates. The second aim was to examine the inuence of hospital

climate perceptions relating to patient care versus more general safetyaspects, separately for both patient and worker-related safety out-

comes. We expected that a more favorable safety climate focusing on

patient care would be associatedwith, not only reduced patient injuries,

but also reduced worker injuries. Similarly, both patient-specic safety

perceptions and generic safety climate would be positively related to

workers’ safety-related behaviors.

2. Method

2.1. Procedure

All 14 NHS Health Boards in Scotland were contacted and asked

to provide an acute hospital for the study, and eight agreed to

participate. One had a low response, another had a high rate of

incomplete data, and they were both excluded. Therefore, the ques-

tionnaire survey was conducted with six hospitals from different

regions of Scotland (during 2009). Paper questionnaires (plus cover-

ing letter and envelope for return) were sent to each participating

hospital. Participants were instructed to return the questionnaires

to the research team or to the collection point within the hospital

unit. No names were requested to enhance anonymity.

Advice obtainedfromthe UK National Research Ethics Service (NRES)

was that this study was a Service Evaluation and therefore would notrequire an NRES ethics application. Ethical approval was obtained from

the ethical committee in the authors’ academic department.

2.2. Sample

The sample consisted of 1866 clinical staff from six NHS acute

hospitals in Scotland, with an estimated 23% response rate (Table 1).

Although the numbers of questionnaires sent to each hospital were

known and used as the denominator, it was not clear how many ques-

tionnaires were actually distributed. The calculated response rate per

hospital ranged from 12% to 31% (probably an underestimate in some

cases, as it later transpired that not all the delivered questionnaires

had been distributed to staff in some units).

2.3. Measure

Scottish Hospital Safety Questionnaire (SHSQ): A questionnaire

was designed for Scottish NHS clinical staff which measured hospital

safety climate and safety outcomes for both workers and patients. The

SHSQ constituted of four components: the 44 items of the Hospital

Survey on Patient Safety Culture (HSOPSC), plus 10 workers ’ safety

behavior items, two items measuring self-reported worker and

patient injuries, and seven demographic questions (see additional

le 1: SHSQ).

2.3.1. Safety climate

The HSOPSC, developed in the USA (Sorra & Nieva, 2006), was

selected as it covers 12 dimensions of safety climate (e.g. hospital

management's commitment to safety, supervisory practices), two of which are labeled as safety outcome measures (‘Overall Perceptions of

Safety’ and ‘Incident reporting’). It also contains two single items

labeled as ‘safety outcome’ measures (‘Patient safety grade’; ‘Number

of incidents reported’). Conrmed as 12 factors for this Scottish sample

(Sarac, Flin, Mearns, & Jackson, 2011), each dimension of safety climate

was assessed by three or four items measured on a 5 point Likert scale,

ranging from strongly disagree to strongly agree, and for Incident

reporting, the scale ranged from never to always. The Patient safety

grade item was measured on a 6 point Likert scale ranging from excel-

lent to failing and the Incident reporting item was assessed on a 6

point Likert scale ranging from no incident reports to 21 or more

incident reports. This climate scale was chosen as it has been used

extensively in northern Europe, (Blegen, Gearhart, O'Brien, Sehgal, &

Alldredge, 2009; Hellings, Schrooten, Klazinga, & Vleugels, 2007;Mardon, Khanna, Sorra, Dyer, & Famolaro, 2010; Olsen, 2010; Pfeiffer

& Manser, 2010; Smits, Dingelhoff, Wagner, van der Wal, &

Groenewegen, 2008) and was recommended by the European Society

Table 1

Overall response rates per Board (one hospital).

Boards Hospital size N returned Response rate (%)

A L 380 20

B M 219 22

C L 250 12

D L 398 27

E L 526 26

H S 93 31

* L ≥500 beds, M=250 –

499 beds, S=50 –

249 beds.

96 C. Agnew et al. / Journal of Safety Research 45 (2013) 95–101


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for Quality in Healthcare (2010). It was decided not to include the four

HSOPSC variables identiedas ‘safety outcome’ measures in the regres-

sion analysis, as these variables did not appear to be very robust mea-

sures of outcome. Instead, safety behavior and injury items derived

from industrial safety research were incorporated, as explained below.

2.3.2. Worker safety behaviors

Health care workers’ safety behaviors can be accessed through

observational techniques (Zohar et al., 2007). However, since obser-vations can be dif cult to gather in hospitals, self report measures

are frequently used to assess safety behaviors such as workers’ safety

compliance and safety participation behaviors (Neal et al., 2000) Pos-

itive associations between safety climate and self-reported measure

of desirable workers’ safety behaviors were shown from a sample of

525 employees in an Australian hospital (Neal et al., 2000). Later,

improvements in these behaviors at the group level were linked to

a reduction in future accident rates (Neal & Grif n, 2006).

The HSOPSC did not contain a safety behavior scale. For this

reason, a ten item scale was included to measure self reports of

workers’ safety compliance and participation behaviors (rated on a

ve-point scale ranging from “strongly disagree” to “strongly

agree”). Safety participation (Cronbach's α=.77) was assessed by 4

items from Neal and Grif n's scale (Neal et al., 2000); an example

item is; “I put in extra effort to improve the safety of the workplace”.

For safety compliance (Cronbach's α=.82), 6 items were incorporat-

ed from safety research on offshore oil installations (Mearns et al.,

2003) and reworded for healthcare workers; an example of a nega-

tively scored item is “I get the job done better by ignoring some

rules”. The ‘rules’ for healthcare staff include behaviors such as hand

washing and reporting incidents (Flin, 2007).

2.3.3. Patient and worker injuries

As it was not possible to obtain hospital-recorded patient or work-

er injury data for this study, in order to measure injuries experienced

both by the workers and patients, two self-report items were used.

The rst item (based on the Offshore Safety Questionnaire (Mearns

et al., 2001)) asked how often the individual had experienced a

work-related injury in this hospital, in the last 12 months. This wasrated on a scale from 0 / None (1) to 5 or more (4). A second question

asked about the number of witnessed errors that had harmed a pa-

tient in the last 12 months, rated on a scale from 0 / None (1) to 15

or more (5), with six options for indicating the reason for the last in-

cident witnessed (based on the question used in the UK NHS Staff

Survey (Aston Business School, 2007).

The rst section asked for biodata: experience within the current

occupation, organization and work area, unit, and the nal section

provided an open space for comments.

2.4. Statistical Analyses

Data analysis was performed using SPSS (version 18). Sample

characteristics, composite mean scores and the average percentageof positive responses were calculated following the reverse coding

the negatively worded items. Next, in order to test the hypotheses

that the higher scores on individual safety climate components

(HSOPSC) were associated with increased workers’ safety behavior

(i.e. higher safety compliance and participation), and lower rates of

self-reported experienced worker and witnessed patient injury

rates, Pearson correlation coef cients were calculated and stepwise

regression analyses (stepwise selection method) were conducted by

entering 10 safety climate dimensions (HSOPSC) as predictors since

it provides the most parsimonious model (Field, 2009) The same

procedure was completed for each of the four outcome measures.

Finally, to assess the impact of climate perceptions related to patient

care separately from more general safety climate on patient and

worker-related safety outcomes, we calculated two composite scores.

The rst composite score consisted of climate items (n=15) that ex-

plicitly mentioned aspects of patient care e.g. “ After we make changes

to improve patient safety, we evaluate their effectiveness.” For the

second composite score, we used the generic items (n=20) that

had no specic focus on patient care, e.g. “Whenever pressure builds

up, my supervisor wants us to work faster , even if it means taking

shortcuts.” We then explored the relationships between workers’

safety behaviors, worker and patient related outcomes with these

two safety climate composite scores (targeting patient care versusgeneric safety climate items) using hierarchical regression models.

3. Results

3.1. Sample characteristics

Nurses constituted the majority of the sample (53%) followed by

Allied Health Professionals (22%), Nursing or Healthcare Assistants

(13%), and Medical and Dental consultants (12%). Regarding the

work area/unit of the respondents, the majority (22%) was from sur-

gical units, followed by medicine (17%). A total of 37% of the partici-

pants had worked more than ten years within their current hospital,

and 32% worked between 1–5 years. Regarding their current profes-

sion, 30% had more than 21 years of experience. The majority of the

staff (74%) worked 20–39 hours, 17% 40–59 hours, and 1.7% worked

more than 60 hours per week. A total of 93% of the respondents

reported having direct contact with patients.

3.2. Descriptive ndings

The composite mean scores and the average percentage of positive

responses were computed for each HSOPSC dimension and outcome

variables (a higher score indicates a more positive response), see

Table 2. Results indicated that Teamwork within units, Supervisors ’

expectations and Organizational learning dimensions were rated

favorably. The highest agreement (73%) was reported for Teamwork

within the units, but Teamwork across units had only 39% positive re-

sponse rate. Less favorable opinions on staf ng levels (45% positive),

and feedback about error within their work unit suggest possibleareas for improvement in relation to patient safety. The scores are

generally comparable with those reported for hospitals in other

northern European countries (cited above).

Regarding the safety outcomes, 81% of the staff reported

complying with the safety rules (M=4.02, SD=0.66) and 75% indi-

cated participating in safety activities (M=3.85, SD=0.59) 0.66).

For worker injuries, 75% of the participants reported no injuries in

the last 12 months, while 21% reported 1 to 2, 4% reported 3 or

Table 2

Means and standard deviations for HSOPSC scores.

HSOPSC SCALES / (Number of items M SD

Safety Climate Dimensions (Unit level)Supervis ors' expectations and actions (4) 3.6 (65%) 0.78

Or ganizat io nal learning - impro vement ( 3) 3.6 (64%) 0.64

Teamwork within hospital units (4) 3.7 (73%) 0.76

Communication openness (3) 3.5 (54%) 0.75

Feedback and communication about err or ( 3) 3.3 (45%) 0.89

Non-punitive response to error (3) 3.2 (44%) 0.85

Staf ng (4) 3.2 (45%) 0.72

Safety Climate Dimensions (Hospital level)

Hospital management support for patient safety (3) 3.0 (38%) 0.83

Teamwork across hospital units (4) 3.0 (39%) 0.70

Hospital handovers (4) 3.2 (32%) 0.64

HSOPSC Outcome Measures

Frequency of incident reporting (3) 3.6 (56%) 0.94

Overall perceptions of safety (4) 3.4 (56%) 0.76

*The average percentages of positive responses are presented in parenthesis.

97C. Agnew et al. / Journal of Safety Research 45 (2013) 95–101


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more incidents. For witnessing incidents harming patients, 40% of the

staff reported witnessing 1–5 incidents in the last year, 3% reported

6–10, 2% reported 11 or more incidents. More than half of the sample

(54%) had not witnessed any incidents harming patients.

3.3. The associations between the HSOPSC dimensions and the safety out-

come measures

In order to examine the associations between HSOPSC climatedimensions and safety outcome measures, Pearson inter-correlation

coef cients were calculated between the 12 dimensions, for the two

HSOPSC outcome measures (patient safety grade and number of inci-

dents reported), the two safety behavior measures, and the two items

measuring the frequency of worker and patient-related injuries in the

last 12 months (see additional le 2: Inter-correlation coef cients be-

tween HSOPSC scales and the outcome measures). The signicant

correlation coef cients between the 12 climate dimensions ranged

between r=.19 and .77 (pb .001), most showing a moderate effect.

For the correlations between the 12 climate dimensions and the safe-

ty behaviors: safety compliance and safety participation, the coef -

cients ranged between r=.07 and .44 (pb .001). Although signicant,

the effect sizes were smaller (ranged between r=− .04 and -.32) when

examined in relation to self-reported worker and patient injuries.

To test the relative inuence of safety climate dimensions on

self-reports of workers’ safety behaviors and worker and patient inju-

ries, as well as to determine the effect size, stepwise regression analyses

were performed. (Examination of variance ination factors and toler-

ance statistics indicated that multi-collinearity was not an issue). A

total of 10 predictor (climate dimensions) and 4 criterion variables

were included in the analysis. As can be seen in Table 3, staf ng levels

and hospital management's support consistently predicted all the out-

come variables. Every criterion measure was predicted by both the

unit and hospital level safety climate dimensions. The safety climate

scores were positively related to self-reported behavioral measures

with two exceptions; non-punitive response to error and staf ng. The

strongest predictor of safetycompliance behavior wasthe staf ng levels

dimension (accounting for 15% of variance). For safety participation

behavior, the dimension of organizational learning was strongest (ac-counting for 10% of the variance). Only three of the climate dimensions

were negatively related to self-reports of worker and patient injury rates.

The climate dimensions of staf ng, communication openness, and

management support explained 6% of variance in worker injuries. For

patient injuries, management support, staf ng and teamwork across

units explained 13% of the variance, (the most signicant was Man-

agement support (Adj R 2=.10).

3.4. The in uence of patient safety climate and generic safety climate on

safety-related outcomes

In order to examine the inuence of staff perceptions of climate

relating to patient care versus generic safety climate on safety related

outcomes for workers and patients, two composite scores were calcu-

lated. Items were selected in relation to their content. For the patient

safety climate perceptions (Cronbach's α=.82), we used 15 items fo-

cusing on patient care (Mean=3.34 SD=0.50) and for the genericitems (Cronbach's α =.89), we calculated the mean of the 20 items

with no specic focus on patient care (Mean= 3.28 SD= 0.54). Hier-

archical regression analyses (Table 4) were carried out to examine

the unique contribution of safety climate perceptions in predicting

worker and patient safety outcomes after controlling for the hospital

effect. Variance ination factors (VIF) and tolerance statistics were

examined among predictors and covariates, and were determined

not to be indicative of multicollinearity (The tolerance statistics

ranged from .361 to .997, and the maximum VIF was 2.77).

The results showed that the perceptions of patient safety climate

were signicantly related to both worker and patient injuries, and

to workers’ safety compliance and participations behaviors (see

Table 4). When more positive perceptions of patient safety climate

were reported, less patient and worker injuries were observed. On

the other hand, more positive patient safety climate was related to

workers’ increased safety compliance and participation behaviors. Re-

sults were mixed for the perceptions of safety climate with no specic

focus on patient care. Although, these generic safety climate scores

were signicantly and negatively related to worker injuries, no such

effect was found for patient injuries. Similarly, workers’ safety com-

pliance behaviors were found to be signicantly increased with more

positive generic safety climate scores, no such an inuence was found

on workers’ safety participation behaviors.

Overall, the results indicated that the two safety climate scores

explained a very small amount of the variance in safety participation

and self reported worker (R 2=.05) and patient injuries (R 2=.09),

and safety participation behaviors (R 2=.05). On the other hand,

both types of safety climate perception explained 21% of the total var-

iance for workers’ safety compliance.

4. Discussion

This study is rst to explore the clinical staff's perceptions of safety

within a sample of Scottish acute hospitals. It used a specially designed

questionnaire, employing the HSOPSC as the main componentof the in-

strument. Although the HSOPSC has been used widely, to date, very few

Table 3

Stepwise Regression Analyses: HSOPSC dimensions as Predictors.

Dependent variables Predictors R Adjusted R 2 B Std β

Safety compliance Staf ng .383 .146 0.17 .19

Supervisors’ Expectations .438 .191 0.13 .15Management Support .465 .215 0.12 .15

Handovers .478 .227 0.12 .12

Communication Openness .481 .229 0.05 .06

Safety participation Organizational learning .312 .097 0.23 .25

Feedback & Communication .327 .106 0.06 .10

Staf ng .345 .118 −0.11 -.13

Communication Openness .349 .120 0.06 .07

Non-punitive response .353 .122 −0.06 -.08

Teamwork Within Units .356 .124 0.05 .06

Management Support .359 .125 0.04 .05

Worker injuries Staf ng .225 .051 −0.14 -.18

Communication Openness .237 .056 −0.05 -.07

Management Support .243 .059 −0.04 -.06

Patient injuries Management Support .321 .103 −0.13 -.15

Staf ng .350 .121 −0.16 -.16

Teamwork Across Units .360 .128 −0.13 -.12

Note: All effects are signicant at pb

.05.



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studies (e.g. Olsen, 2010) examined its associations with additional

measures, such as self-reported safety behaviors and injury rates.

The descriptive data illustrated areas of strength and of concern re-

lating to safety climate within each participating hospital. For example,

the unit level dimensions were found to receive more favorable re-

sponses compared to hospital level safety climate scales. Specically,

scales concerned with supervisory practices, improvement efforts at

the unit level, and teamwork were signicantly higher than the rest of

the sub-scales. At the unit level, the staf ng dimension was a perceived

challenge by the respondents. Respondents seemed to be more cynical

about their hospital management but were more favorable about their

own work area, for example, handovers across units were perceived

less positively than teamwork within units. Similar to previous studies

showing respondents reporting more compliance with the safety rules

compared to voluntary safety-related activities (Neal & Grif n, 2006;

Neal et al., 2000), results showed that overall safety compliance re-

ceived higher scores compared to safety participation scale.

In respect to self-reported injury rates, more than half of the re-

spondents (54%) reported not witnessing any patient injuries. Most

respondents (75%) reported not experiencing any work-related inju-

ries. An earlier NHS survey (Healthcare Commission, 2007), found

79% of staff reported not seeing any incidents that could have hurtstaff and 75% had not seen any incidents or near- misses that could

have hurt patients, in the last 12 months.

4.1. Associations between HSOPSC scores and the self-reported outcome

measures

The associations between the HSOPSC dimensions and the

safety outcome variables were examined via regression analyses. The

results revealed that the climate dimensions of staf ng and hospital

management's support were signicantly related to every outcome

measure. The impact of staf ng adequacy in hospitals has been the sub-

ject of a major investigation where staf ng cuts andtheir impact on pa-

tient care in an English hospital have been highlighted (Francis, 2013).

Inadequate staf ng levels and staff workload have also been identiedas key variables determining outcomes such as hospital mortality

rates (Needleman,Buerhaus, & Pankratz, 2011), nurseburnout, dissatis-

faction (Holden et al., 2011) and prolonged length of stay (Blegen,

Goode, Spetz, Vaughn, & Park, 2011) We also expected that increased

safety participation would be reported in relation to better staf ng

levels. In fact, the results showed decreased ratherthan increased safety

participation when the staf ng levels were perceived favorably. Re-

spondents who are experiencing staff shortages and higher workload

maytake short cuts and comply less with the safety protocols.However,

in the short term, they mayengagein more voluntarysafetyactivities in

order to compensate forthe negative effects of staff shortageson patient

care. In this sense, a good teamwork climate might help to mitigate the

adverse consequences of perception of inadequate staf ng (Siassakos et

al., 2011). Favorable staf ng levels on the other hand, might contribute

to diffusion of responsibility withinthe workgroups; leading to workers

failing to take individual action and therefore reporting decreased vol-

untary safety activities.

The observed effects of the climate scales on worker and patient-

related injuries were smaller than the effects of climate on the behav-

ioral measures of safety compliance and safety participation. This

nding is supported by a meta-analysis (Christian et al., 2009) show-

ing safety climate perceptions were a more proximal measure of safe-

ty behaviors than of worker injuries. However, as mentioned above,

75% participants did not report any work-related injuries, a rate which

is not dissimilar to other industries (Mearns et al., 2001).

Finally, we found that patient-specic safety climate was related to

both worker and patient related outcomes, whereas generic safety cli-

mate scores only had an impact on worker safety compliance behaviors

and worker injury rates. The association of patient safety climate with

both worker and patient safety outcomes replicates the ndings of

Hofmann and Mark (2006) and Taylor et al. (2012), indicating a poten-

tial common causal effect. Future research should test facets of safety

climate against specic types of worker behaviors (as in this study)

and also against particular categories of worker and patient injuries,

extending the approach taken by Taylor et al. (2012).

4.2. Limitations

One of the limitations of the current study was the low response

rate. In order to maximize response rates, an online version of the

questionnaire was prepared and a condential feedback report was

offered to the participating hospitals. Although a reasonable sample

size was achieved, the overall estimated response rate remained

low (23%), and so there is a risk of selection bias in that the percep-

tions of safety culture reported might not represent the views of

non-respondents (Groves & Peytcheva, 2008). Rogelberg, Luong,

Sederburg, and Cristol (2000) found that workers who do not comply

to organizational survey requests show lower organizational commit-

ment, and less satisfaction with supervisors. In future, additional ef-

fort should be made to obtain a higher level of local support andmanagerial involvement prior to the data collection, as well as more

consultation with the government health department to reduce the

risk of scheduling conicts with other surveys.

For the comparison of generic and patient-specic safety climates,

the items were selected thematically and then the internal consistency

of the derived scales was established. This was an exploratory exercise

and we recognize that this is a preliminary analysis that would require

replication, ideally with independent generic (e.g. from industry or

worker safety research) and patient safety-specic climate scales.

Perceptions of safety climate factors and on self-reported safety out-

comes (safety behaviors and worker and patient injury rates) were col-

lected froma singlesourcewhere thereis a riskof commonmethod bias

(Podsakoff & Organ, 1986), that can inate the relationships between

the variables (Podsakoff, MacKenzie, Lee, & Podsakoff, 2003). It is

Table 4

Hierarchical Regression Results for Safety compliance, safety participation, worker and patient injuries.

Safety compliance Safety participation Worker injuries Patient injuries

Predictor variables Std β B Std β B Std β B Std β B

First step: control variables

Constant 4.03 3.87 1.33 1.50

Hospital -.01 -.001 -.01 −0.003 -.02 −0.01 .03 0.01

Second step: Independent variables

Constant 1.93 2.95 2.19 2.99

Hospital .01 0.004 -.004 −0.001 -.03 −0.01 .01 0.004

Patient safety climate .37** 0.49 .17** 0.20 -.08* −0.09 -.28** −0.40

Generic safety climate .13** 0.13 .07 0.08 -.15** −0.17 -.03 −0.05

R 2=.00 for Step 1

ΔR 2=.21** for Step 2

R 2=.01 for Step 1


R 2=.00 for Step 1


R 2=.00 for Step 1


**pb .01, *pb .05.



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also important to note the cross-sectional study design and the use of

retrospective self-reported injury data. For this reason, it was not pos-

sible to ascertain the direction of the causality.

4.3. Conclusions and impact on industry

The Scottish Hospital Safety Questionnaire with the combination of

climate, behavioral and outcome measures was found to produce an in-

formative data set on the level and components of the hospitals’ safetyculture. The resulting prole revealed areas of strength but also of con-

cern, relating to staf ng levels and hospital management'scommitment

to safety, factors which were associated with poorer safety outcomes.

Based on these ndings, it is suggested that healthcare organizations

need to ensure strong managerial commitment to safety and address

staf ng decits in order to achieve the desired level of safety. Finally,

by demonstrating the impact of staff perceptions of patient safety cli-

mate on the safety of both patients and workers, this study illustrates

that a safety climate supporting patient care should also help to ensure

the safety of clinical workers.

Competing interest

None declared.

Author contributions

CA, RF & KM were responsible for the study conception and

design. CA performed the data collection, the data analysis and was

responsible for the drafting of the manuscript. CA, RF & KM made

critical revisions to the paper for important intellectual content. RF

obtained funding.

Funding

This research was funded by a Scottish Funding Council Strategic

Research Development Grant to the Scottish Patient Safety Research

Network.

Acknowledgements

We would like to thank all the NHS Scotland staff who gave their

time to complete our questionnaire.

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http://www.nhsstaffsurveys.com/http://www.cqc.org.uk/_db/_documents/National_NHS_staff_survey_2007_summary_of_key_findings_200804183620.pdfhttp://www.cqc.org.uk/_db/_documents/National_NHS_staff_survey_2007_summary_of_key_findings_200804183620.pdfhttp://www.cqc.org.uk/_db/_documents/National_NHS_staff_survey_2007_summary_of_key_findings_200804183620.pdfhttp://www.cqc.org.uk/_db/_documents/National_NHS_staff_survey_2007_summary_of_key_findings_200804183620.pdfhttps://handson.hse.gov.uk/hse/public/tablesimple.aspx?RID15https://handson.hse.gov.uk/hse/public/tablesimple.aspx?RID15https://handson.hse.gov.uk/hse/public/tablesimple.aspx?RID15http://www.patientsafetyalliance.scot.nhs.uk/programme/http://www.patientsafetyalliance.scot.nhs.uk/programme/http://www.patientsafetyalliance.scot.nhs.uk/programme/http://www.patientsafetyalliance.scot.nhs.uk/programme/https://handson.hse.gov.uk/hse/public/tablesimple.aspx?RID15https://handson.hse.gov.uk/hse/public/tablesimple.aspx?RID15http://www.cqc.org.uk/_db/_documents/National_NHS_staff_survey_2007_summary_of_key_findings_200804183620.pdfhttp://www.cqc.org.uk/_db/_documents/National_NHS_staff_survey_2007_summary_of_key_findings_200804183620.pdfhttp://www.cqc.org.uk/_db/_documents/National_NHS_staff_survey_2007_summary_of_key_findings_200804183620.pdfhttp://www.nhsstaffsurveys.com/


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Cakil Agnew was a Research Fellow at the University of Aberdeen, where she receivedher doctoral degree in Applied Psychology. Her research interests include safety cul-ture and leadership behaviours in healthcare.

Rhona Flin is Professor of Applied Psychology and Director of the IndustrialPsychology Research Centre at the University of Aberdeen. Her research

interests include non-technical skills in safety critical occupations and safetyculture.

KathrynMearns was a Senior Lecturer at the University of Aberdeen. She has specic in-terests in risk management and safety culture (which she has studied in the oil industryand air traf c management) and is now a human factors inspector for a safety regulator.

Appendix 1

Inter-correlation coef cients between HSOPSC scales and the outcome measures.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

1. Supervisors’ Expectations -

2. Organizational Learning .51 -

3. Teamwork Within Units .47 .52 -

4. Communication Openness .53 .45 .50 -

5. Feedback & Communication .51 .52 .44 .61 -

6. Non-punitive Response .44 .36 .43 .46 .38 -

7. Staf ng .44 .35 .40 .37 .37 .47 -8. Management Support .40 .36 .32 .32 .42 .30 .43 -

9. Teamwork Across Units .32 .32 .40 .31 .36 .30 .35 .51 -

10. Hospital Handovers .30 .22 .28 .29 .26 .28 .36 .34 .43 -

11. Incident Reporting .29 .33 .22 .31 .38 .19 .20 .24 .19 .22 -

12. Overall Perceptions of Safety .53 .49 .48 .45 .45 .44 .77 .48 .42 .36 .31 -

13. Incidents Reported -.05* .07 -.05 -.02 -.04 -.03 -.13 -.06 -.12 -.06* .12 -.10 -

14. Patient Safety Grade .48 .48 .47 .46 .48 .35 .51 .47 .39 .36 .33 .63 -.08 -

15. Safety Compliance .36 .23 .25 .30 .29 .25 .39 .35 .26 .30 .27 .44 -.09 .41 -

16. Safety Participation .19 .30 .19 .21 .24 .07 .03ns .14 .10 .11 .23 .11 .15 .16 .22 -

17. Worker Injuries -.15 -.09 -.13 -.16 -.12 -.17 -.23 -.16 -.14 -.14 -.04 -.17 .19 -.18 -.14 .06* -

18. Patient Injuries -.18 -.14 -.15 -.15 -.19 -.13 -.26 -.27 -.25 -.25 -.11 -.32 .28 -.30 -.25* .01ns .19

Note: All effects are signicant at pb .001, *pb .05, ns: Non-signicant.


Documents

Patient Safety Climate and Worker Safety Behaviours