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Nursing Work and Life
Nurses’ perceptions of patient safety culture in Jordanian hospitals W.A. Khater1 RN, PhD, L.M. Akhu-Zaheya2 RN, MSN & R. Khater4 MD, CPHQ
RN, PhD, S.I.
AL-Mahasneh3
1 Assistant Professor, 2 Associate Professor, Jordan University of Science and Technology, 3 Registered Nurse, King Abdullah University Hospital, Irbid, 4 Quality Manager, Prince Hamzah Hospital, Amman, Jordan
KHATER W.A., AKHU-ZAHEYA L.M., AL-MAHASNEH S.I. & KHATER R. (2015) Nurses’ perceptions of patient safety culture in Jordanian hospitals. International Nursing Review 62, 82–91 Background: Patients’ safety culture is a key aspect in determining healthcare organizations’ ability to address and reduce risks of patients. Nurses play a major role in patients’ safety because they are accountable for direct and continuous patient care. There is little known information about patients’ safety culture in Jordanian hospitals, particularly from the perspective of healthcare providers. Aim: The study aimed to assess patient safety culture in Jordanian hospitals from nurses’ perspective. Methods: A cross-sectional, descriptive design was utilized. A total number of 658 nurses participated in the current study. Data were collected using an Arabic version of the hospital survey of patients’ safety culture. Findings: Teamwork within unit dimensions had a high positive response, and was perceived by nurses to be the only strong suit in Jordanian hospitals. Areas that required improvement, as perceived by nurses, are as follows: communication openness, staffing, handoff and transition, non-punitive responses to errors, and teamwork across units. Regression analysis revealed factors, from nurses’ perspectives, that influenced patients’ safety culture in Jordanian hospital. Factors included age, total years of experience, working in university hospitals, utilizing evidence-based practice and working in hospitals that consider patient safety to be a priority. Limitations: Participants in this study were limited to nurses. Therefore, there is a need to assess patient safety culture from other healthcare providers’ perspectives. Moreover, the use of a self-reported questionnaire introduced the social desirability biases. Conclusion: The current study provides insight into how nurses perceive patient safety culture. Results of this study have revealed that there is a need to replace the traditional culture of shame/blame with a non-punitive culture. Implications for nursing and health policy: Study results implied that improving patient safety culture requires a fundamental transformation of nurses’ work environment. New policies to improve collaboration between units of hospitals would improve patients’ safety. Keywords: Hospital Survey of Patients’ Safety Culture, Jordan, Nurses’ Perceptions, Patients’ Safety Culture
Correspondence address: Wejdan A. Khater, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan; Tel: +962-2-7201000 (Ext. 23715); Fax: 96227095012; E-mail: [email protected].
No conflict of interest has been declared by the authors.
© 2014 International Council of Nurses
82
Patient safety culture
Introduction The Institute of Medicine (1999) report, ‘To Err Is Human’, highlights the need to create a culture of safety within healthcare organizations. According to this report errors that occur in healthcare setting are frequently system related, which implies the need to improve healthcare systems instead of blaming individuals. In accordance with this change in culture, health organizations worldwide are striving to improve the quality of patients’ care and safety through the creation of a patient safety culture. Patient safety culture is defined as ‘values shared among organization members about what is important, their beliefs about how things operate in the organization and the interaction of these with work unit and organizational structures, and systems, which together produce behavioural norms in the organization that promotes safety (Singer et al. 2009, p. 400). Patient safety culture is the product of individual, group or social learning; ways of thinking; and behaviours that are shared to meet the primary objective of patient safety (Mustard 2002, p. 112). Several initiatives had been implemented by many health organizations such as the Accreditations Achievement and Patient Safety Friendly Hospital Initiative, which aimed to improve patient safety culture and to deal with the unsafe healthcare practices in Eastern Mediterranean Regional the Office of the World Health Organization (WHO) (Siddiqi et al. 2012). Despite all initiatives, the adverse events have markedly increased worldwide. The overall reported prevalence of adverse events ranges between 2.9 and 28%, including medication errors, incorrect diagnosis, hospitalacquired infections, bed sores and falls (Hayajneh et al. 2010). Jordan is no exception. Using 75 valid web-based responses, adverse events are determined to be 28% of all admitted cases in the participants’ hospitals (Hayajneh et al. 2010). This figure is considered to be far above average, in comparison with the WHO estimation that it is approximately 10% of all inpatient in Eastern Mediterranean Region (World Health Organization 2007). Nevertheless, there is a compelling need to maximize the concept of patient safety and to build a positive patient safety culture. First step in creating patient safety culture is assessing the existing culture (Mikušová et al. 2012). Assessment of patient safety culture refers to understanding the organization’s beliefs, norms and values, as well as individual’s attitudes and behaviours related to patient safety culture (Sorra et al. 2012). Assessing healthcare providers’ perception of patient safety culture would provide valuable information for both administrators and policy makers. Nurses as healthcare providers
© 2014 International Council of Nurses
83
believe that patient safety is primarily a nursing responsibility (Abdou & Saber 2011; Aboshaiqah 2010). It was estimated that more than 90% of potential medication errors were discovered by nurses prior to administration (Ross 2011). Nurses are key to safety improvement in many aspects (Richardson & Storr 2010). However, building on the Institute of Medicine reports a guideline of ‘Keeping Patients Safe: Transforming the Work Environment of Nurses’ illustrated the linkage between patient safety and nurses’ work environment, and demonstrated that nurses play a crucial role in the occurrence of medical errors. The report extrapolates that unclear unit values, fear of punishment, a lack of mistakes analysis, complexity and workload, and lack of team work are the leading causes of patient safety problems related to nurses (National Research Council 2004). The IOM stressed that unclear unit values may lead to adverse events, and a number of nurses neglected the existence of unit values (Institute of Medicine 2004). Nurses, instead, focus on their own values when it comes to decisions related to nursing care (Kalisch & Aebersold 2006). However, literature regarding nursing and patient safety concluded that gaps in nursing patient safety knowledge exist (Richardson & Storr 2010). Thus, understanding nurses’ perception of patient safety culture is vital for policy makers to address patient safety culture from nurses’ staffing policies. Studies disclosed that nurses’ perception of patient safety correlated with the demands of work (Richardson & Storr 2010; Ross 2011). Nurses’ perception of patient safety increased when the work demands decreased, whereas nurses who worked fulltime harboured lower perceptions of patient safety on their unit. Furthermore, the nursing environment such as the arrangement of nursing units, technological equipment, communication, knowledge transfer among staff, inadequate policies, fatigue, stress and an incredible workload are significant factors affecting patient safety and the quality of care (Aboshaiqah & Baker 2013; Keller 2009; Ross 2011; Zakari 2011). In Jordan, since the establishment of the Health Care Accreditation Council (HCAC) in 2007, the awareness of accreditation has improved and there is a policy now implemented throughout Jordanian hospitals (World Health Organization 2013). To date, more than 17 public and private hospitals have been accredited by the Joint Commission International and/or HCAC, in addition to more than 42 primary healthcare centres accredited by the HCAC (World Health Organization 2013). Despite these initiatives to implement patient safety, little is known about patient safety culture in Jordanian hospitals. Therefore, the main purpose of the current study was to assess patient safety culture in Jordanian hospitals from nurses’ perspective.
84
W. A. Khater et al.
The study was conducted to answer the following research questions: 1 How do nurses working at Jordanian hospitals perceive patient safety culture? 2 What are the factors influencing patient safety culture in Jordanian Hospitals?
Methods Design
A quantitative, descriptive–comparative, cross-sectional design employing self-reported questionnaires over 2 months of data collection was utilized so as to assess patient’s safety culture from nurses’ perspective at a Jordanian hospital.
Setting
The study was conducted in the Middle Region and Northern Region of Jordan. The Middle Region and Northern Region involved eight governorates out of a total of 13 governorates in Jordan. In the current study, we included the smallest and largest governmental hospitals, as well as the largest private hospitals from the selected regions. The largest and smallest hospitals were chosen according to the number of beds in the hospital based on the Jordanian Ministry of Health Statistics. In addition, two university-affiliated hospitals were included. The total number of hospitals was 21 hospitals: two are universityaffiliated hospitals, four are private hospitals and 15 are governmental hospitals.
Participants
The target population included all registered nurses (RNs) who met the inclusion criteria of being able to write and read Arabic, with at least 1 year of experience in the unit to ensure that they are familiar with the unit’s policy and rules. The accessible population included RNs who were working in the hospital’s approached. The RNs who were available at the time of data collection in the approached hospitals and agreed to participate by signing consent were selected. Exclusion criteria included practical nurses with a diploma degree, as their responsibilities were not directly related to patient care in governmental and private hospitals. In addition, RNs with less than a year of experience were excluded to ensure that nurses were involved more in direct patient care. The sample size was determined using power analysis, at a level of significant 0.05 and power 0.80, and linear regression test, whereby the minimum sample size required was 107 participants (Cohen 1992). However, as it is a pioneer study in this
© 2014 International Council of Nurses
area, more samples approached to gain more understanding of phenomena. The final sample obtained was 658 RNs. Measure
The current study utilized the Arabic version of Hospital Survey of Patients’ Safety Culture (HSOPSC), which was translated and utilized by El-Jardali et al. (2011). A formal request and approval to use the measure was acquired. The HSOPSC is a survey that assesses patient safety culture based on the perspectives of health team members. HSOPSC can be used in order to measure patient safety culture dimensions, either for the whole hospital or for its specific units (Sorra et al. 2012). The original HSOPSC included 12 safety culture dimensions, including ten patient safety culture dimensions and two outcome dimensions. The ten patient safety culture dimensions included seven unit-level dimensions and three hospitallevel dimensions. The total number of items are 43 of 5-point Likert scale ranging from 1 = ‘strongly disagree’ to 5 = ‘strongly agree’ (see Table 2). The survey’s score represented the frequency of responses for each survey’s item. The item’s score reflected the hospital’s strength and areas in need of improvement, which was determined by measuring positive responses’ frequency and percentage for each item [(number of positive response/total number of respondent on the item) × 100%]. Areas of strength were identified as those items that about 75% of respondents endorsed positively (by answering strongly agree/agree or always/most of the time), whereas areas requiring improvement were identified as those items scoring 50% or less (Sorra et al. 2012). In addition, the questionnaire included a demographic characteristics part, which included age, gender, marital status, educational level, total years of experience, years of experience in current hospital, years of experience in current unit, total weekly working hours and if participant worked in shifting programme. In addition, it included some situation-related characteristics such as the number of beds in the current hospital, the number of beds in the working unit, the type of hospital, if participant work according to evidence-based practice and if hospital consider patient safety as a top priority. In addition, two open-ended questions, whether or not participant trained for patient safety, and what are the most important three things to improve patient safety were included. Regarding the reliability of instruments, the HSOPSC survey was utilized in numerous countries including the United States, Canada and Belgium, and translated to different languages such as Taiwanese, Turkish and Arabic. The reliability measured by Cronbach’s coefficient alpha of the original English version ranged between 0.63 and 0.84 (Sorra & Dyer 2010; Sorra &
Patient safety culture
Nieva 2004), whereas for the Arabic version, it ranged between 0.45 and 0.81 (El-Jardali et al. 2010). In the current study, Cronbach’s coefficient alpha values ranged from 0.41 to 0.78. Ethical consideration
Formal approval from the institutional review board at the Jordan University of Science and Technology, Ministry of Health, and hospital administrators was attained. Consent forms were obtained from all participants. Full disclosure of the study’s purposes and significance was provided to all. Additionally, participants were assured that participation was voluntary. Furthermore, the acquired data will be kept both anonymous and confidential. In addition, approval to use the instrument was granted. Procedures and data collection
Once the IRB’s approval was obtained, a request to collect the data was sent to the Jordanian Ministry of Health (MOH), and the administrator of each private and university hospital attained approval for the distribution of the questionnaire. An envelope included a self-reported questionnaire, with a cover letter explaining the study purposes, outcomes and instructions were provided to the in-charge nurse by the researcher and her assistant to distribute the envelopes to eligible nurses at different units. Envelopes were given to the in-charge nurses in each unit at the beginning of the ‘A’ shift and returned in a timely manner, in the same day.
85
26 years (M = 7.5 years, SD = 5.377). The mean of nurses’ experience in their current working hospital was 6.37 years (SD = 5.129, R = 1–25), and the mean of nurses’ experience in their current working unit was 4.8 years (SD = 4.321, R = 1–22). Of the participants, 66.6% (n = 438) were working 8 h shift per day, while 33.4% (n = 220) worked more than 8 h per day. In addition, the mean of total weekly working hours was 46.91 h (SD = 3.54, R = 40–58). Participating nurses worked within different hospital sectors including governmental, university and private hospitals with a percentage of 66.9, 23.6 and 9.5%, respectively. For the unit/area of working, a total of 141 nurses (21.3%) worked in intensive care units (ICUs) (general ICU, paediatric ICU, neonatal ICU, cardiac ICU and coronary care unit). Other nurses worked at surgical, medical and emergency units with percentages of 16.6, 13.7 and 11.9%, respectively. Nurses worked in hospitals with less than 100 beds (21.9%, n = 144), between 100 and 300 beds (41%, n = 270) and more than 300 beds (37.1%, n = 244). For the hospital units’ bed, nurses worked in units with less than 20 beds (56.8%; n = 374), between 20 and 40 beds (32.1%; n = 211) and more than 40 beds (11.1%; n = 73). Although 46.7% (n = 307) of the respondents reported that they use evidencebased practice, the remaining 53.3% (n = 351) did not. Most of the nurses in Jordanian hospitals 81% (n = 533) stated that patients’ safety was a priority in their current working hospital. Furthermore, 76.6% (n = 503) of nurses received training on patient safety while 23.4% (n = 154) did not receive any training (see Table 1).
Data analysis plan
Descriptive statistic, frequencies and percentages according to the level of measurement were used. In addition, multivariate analysis – linear regression – was used to look at the factors that would influence patient safety culture in Jordanian hospitals.
Results Participants’ characteristics
A total of 797 participants were approached; however, 663 questionnaires were returned with a total response rate of 83.1%. Five questionnaires were excluded, either because they did not meet the inclusion criteria (four filled by practical nurses) or due to missing data. Therefore, the total number of participants was N = 658. Of all participants (N = 658), 59.9% (n = 394) were female RNs and 40.1% (n = 264) were male RNs. Nurses’ mean age was 30 years [standard deviation (SD) = 5.76, R = 22–55]. Most of nurses 87.1% (n = 573) hold a bachelor degree, whereas 8.5% (n = 56) hold a 3-year diploma and 4.4% (n = 29) of nurses hold a master degree. Nurses’ experience ranged between 1 and
© 2014 International Council of Nurses
How do nurses at Jordanian hospitals perceive patients’ safety culture?
Patient safety culture in Jordanian hospitals from nurses’ perspective was appraised by the composite frequency of each dimensions, and by verifying areas of strength and areas necessitating improvement, with respect to patients’ safety issues. The study results revealed that the composite frequencies ranged between 21 and 78.8%. The highest composite frequency of patient safety related to unit-level dimension was 79%, reflecting nurses’ positive perception of team work within the unit, while the lowest composite frequency (21%) means that only 21% of the nurse’s responses reflected positive opinion about the non-punitive response to errors. For hospital-level dimensions of patient safety, the highest composite frequency was related to nurses’ positive opinion of the management support for patients’ safety (53.5%). For the outcome variables, the highest composite frequency related to the frequency of reporting events (69.2%) (see Table 2). From the nurses’ perspective, the major areas needing improvement (percentage of items positive response
Nursing Work and Life
Nurses’ perceptions of patient safety culture in Jordanian hospitals W.A. Khater1 RN, PhD, L.M. Akhu-Zaheya2 RN, MSN & R. Khater4 MD, CPHQ
RN, PhD, S.I.
AL-Mahasneh3
1 Assistant Professor, 2 Associate Professor, Jordan University of Science and Technology, 3 Registered Nurse, King Abdullah University Hospital, Irbid, 4 Quality Manager, Prince Hamzah Hospital, Amman, Jordan
KHATER W.A., AKHU-ZAHEYA L.M., AL-MAHASNEH S.I. & KHATER R. (2015) Nurses’ perceptions of patient safety culture in Jordanian hospitals. International Nursing Review 62, 82–91 Background: Patients’ safety culture is a key aspect in determining healthcare organizations’ ability to address and reduce risks of patients. Nurses play a major role in patients’ safety because they are accountable for direct and continuous patient care. There is little known information about patients’ safety culture in Jordanian hospitals, particularly from the perspective of healthcare providers. Aim: The study aimed to assess patient safety culture in Jordanian hospitals from nurses’ perspective. Methods: A cross-sectional, descriptive design was utilized. A total number of 658 nurses participated in the current study. Data were collected using an Arabic version of the hospital survey of patients’ safety culture. Findings: Teamwork within unit dimensions had a high positive response, and was perceived by nurses to be the only strong suit in Jordanian hospitals. Areas that required improvement, as perceived by nurses, are as follows: communication openness, staffing, handoff and transition, non-punitive responses to errors, and teamwork across units. Regression analysis revealed factors, from nurses’ perspectives, that influenced patients’ safety culture in Jordanian hospital. Factors included age, total years of experience, working in university hospitals, utilizing evidence-based practice and working in hospitals that consider patient safety to be a priority. Limitations: Participants in this study were limited to nurses. Therefore, there is a need to assess patient safety culture from other healthcare providers’ perspectives. Moreover, the use of a self-reported questionnaire introduced the social desirability biases. Conclusion: The current study provides insight into how nurses perceive patient safety culture. Results of this study have revealed that there is a need to replace the traditional culture of shame/blame with a non-punitive culture. Implications for nursing and health policy: Study results implied that improving patient safety culture requires a fundamental transformation of nurses’ work environment. New policies to improve collaboration between units of hospitals would improve patients’ safety. Keywords: Hospital Survey of Patients’ Safety Culture, Jordan, Nurses’ Perceptions, Patients’ Safety Culture
Correspondence address: Wejdan A. Khater, Jordan University of Science and Technology, P.O. Box 3030, Irbid 22110, Jordan; Tel: +962-2-7201000 (Ext. 23715); Fax: 96227095012; E-mail: [email protected].
No conflict of interest has been declared by the authors.
© 2014 International Council of Nurses
82
Patient safety culture
Introduction The Institute of Medicine (1999) report, ‘To Err Is Human’, highlights the need to create a culture of safety within healthcare organizations. According to this report errors that occur in healthcare setting are frequently system related, which implies the need to improve healthcare systems instead of blaming individuals. In accordance with this change in culture, health organizations worldwide are striving to improve the quality of patients’ care and safety through the creation of a patient safety culture. Patient safety culture is defined as ‘values shared among organization members about what is important, their beliefs about how things operate in the organization and the interaction of these with work unit and organizational structures, and systems, which together produce behavioural norms in the organization that promotes safety (Singer et al. 2009, p. 400). Patient safety culture is the product of individual, group or social learning; ways of thinking; and behaviours that are shared to meet the primary objective of patient safety (Mustard 2002, p. 112). Several initiatives had been implemented by many health organizations such as the Accreditations Achievement and Patient Safety Friendly Hospital Initiative, which aimed to improve patient safety culture and to deal with the unsafe healthcare practices in Eastern Mediterranean Regional the Office of the World Health Organization (WHO) (Siddiqi et al. 2012). Despite all initiatives, the adverse events have markedly increased worldwide. The overall reported prevalence of adverse events ranges between 2.9 and 28%, including medication errors, incorrect diagnosis, hospitalacquired infections, bed sores and falls (Hayajneh et al. 2010). Jordan is no exception. Using 75 valid web-based responses, adverse events are determined to be 28% of all admitted cases in the participants’ hospitals (Hayajneh et al. 2010). This figure is considered to be far above average, in comparison with the WHO estimation that it is approximately 10% of all inpatient in Eastern Mediterranean Region (World Health Organization 2007). Nevertheless, there is a compelling need to maximize the concept of patient safety and to build a positive patient safety culture. First step in creating patient safety culture is assessing the existing culture (Mikušová et al. 2012). Assessment of patient safety culture refers to understanding the organization’s beliefs, norms and values, as well as individual’s attitudes and behaviours related to patient safety culture (Sorra et al. 2012). Assessing healthcare providers’ perception of patient safety culture would provide valuable information for both administrators and policy makers. Nurses as healthcare providers
© 2014 International Council of Nurses
83
believe that patient safety is primarily a nursing responsibility (Abdou & Saber 2011; Aboshaiqah 2010). It was estimated that more than 90% of potential medication errors were discovered by nurses prior to administration (Ross 2011). Nurses are key to safety improvement in many aspects (Richardson & Storr 2010). However, building on the Institute of Medicine reports a guideline of ‘Keeping Patients Safe: Transforming the Work Environment of Nurses’ illustrated the linkage between patient safety and nurses’ work environment, and demonstrated that nurses play a crucial role in the occurrence of medical errors. The report extrapolates that unclear unit values, fear of punishment, a lack of mistakes analysis, complexity and workload, and lack of team work are the leading causes of patient safety problems related to nurses (National Research Council 2004). The IOM stressed that unclear unit values may lead to adverse events, and a number of nurses neglected the existence of unit values (Institute of Medicine 2004). Nurses, instead, focus on their own values when it comes to decisions related to nursing care (Kalisch & Aebersold 2006). However, literature regarding nursing and patient safety concluded that gaps in nursing patient safety knowledge exist (Richardson & Storr 2010). Thus, understanding nurses’ perception of patient safety culture is vital for policy makers to address patient safety culture from nurses’ staffing policies. Studies disclosed that nurses’ perception of patient safety correlated with the demands of work (Richardson & Storr 2010; Ross 2011). Nurses’ perception of patient safety increased when the work demands decreased, whereas nurses who worked fulltime harboured lower perceptions of patient safety on their unit. Furthermore, the nursing environment such as the arrangement of nursing units, technological equipment, communication, knowledge transfer among staff, inadequate policies, fatigue, stress and an incredible workload are significant factors affecting patient safety and the quality of care (Aboshaiqah & Baker 2013; Keller 2009; Ross 2011; Zakari 2011). In Jordan, since the establishment of the Health Care Accreditation Council (HCAC) in 2007, the awareness of accreditation has improved and there is a policy now implemented throughout Jordanian hospitals (World Health Organization 2013). To date, more than 17 public and private hospitals have been accredited by the Joint Commission International and/or HCAC, in addition to more than 42 primary healthcare centres accredited by the HCAC (World Health Organization 2013). Despite these initiatives to implement patient safety, little is known about patient safety culture in Jordanian hospitals. Therefore, the main purpose of the current study was to assess patient safety culture in Jordanian hospitals from nurses’ perspective.
84
W. A. Khater et al.
The study was conducted to answer the following research questions: 1 How do nurses working at Jordanian hospitals perceive patient safety culture? 2 What are the factors influencing patient safety culture in Jordanian Hospitals?
Methods Design
A quantitative, descriptive–comparative, cross-sectional design employing self-reported questionnaires over 2 months of data collection was utilized so as to assess patient’s safety culture from nurses’ perspective at a Jordanian hospital.
Setting
The study was conducted in the Middle Region and Northern Region of Jordan. The Middle Region and Northern Region involved eight governorates out of a total of 13 governorates in Jordan. In the current study, we included the smallest and largest governmental hospitals, as well as the largest private hospitals from the selected regions. The largest and smallest hospitals were chosen according to the number of beds in the hospital based on the Jordanian Ministry of Health Statistics. In addition, two university-affiliated hospitals were included. The total number of hospitals was 21 hospitals: two are universityaffiliated hospitals, four are private hospitals and 15 are governmental hospitals.
Participants
The target population included all registered nurses (RNs) who met the inclusion criteria of being able to write and read Arabic, with at least 1 year of experience in the unit to ensure that they are familiar with the unit’s policy and rules. The accessible population included RNs who were working in the hospital’s approached. The RNs who were available at the time of data collection in the approached hospitals and agreed to participate by signing consent were selected. Exclusion criteria included practical nurses with a diploma degree, as their responsibilities were not directly related to patient care in governmental and private hospitals. In addition, RNs with less than a year of experience were excluded to ensure that nurses were involved more in direct patient care. The sample size was determined using power analysis, at a level of significant 0.05 and power 0.80, and linear regression test, whereby the minimum sample size required was 107 participants (Cohen 1992). However, as it is a pioneer study in this
© 2014 International Council of Nurses
area, more samples approached to gain more understanding of phenomena. The final sample obtained was 658 RNs. Measure
The current study utilized the Arabic version of Hospital Survey of Patients’ Safety Culture (HSOPSC), which was translated and utilized by El-Jardali et al. (2011). A formal request and approval to use the measure was acquired. The HSOPSC is a survey that assesses patient safety culture based on the perspectives of health team members. HSOPSC can be used in order to measure patient safety culture dimensions, either for the whole hospital or for its specific units (Sorra et al. 2012). The original HSOPSC included 12 safety culture dimensions, including ten patient safety culture dimensions and two outcome dimensions. The ten patient safety culture dimensions included seven unit-level dimensions and three hospitallevel dimensions. The total number of items are 43 of 5-point Likert scale ranging from 1 = ‘strongly disagree’ to 5 = ‘strongly agree’ (see Table 2). The survey’s score represented the frequency of responses for each survey’s item. The item’s score reflected the hospital’s strength and areas in need of improvement, which was determined by measuring positive responses’ frequency and percentage for each item [(number of positive response/total number of respondent on the item) × 100%]. Areas of strength were identified as those items that about 75% of respondents endorsed positively (by answering strongly agree/agree or always/most of the time), whereas areas requiring improvement were identified as those items scoring 50% or less (Sorra et al. 2012). In addition, the questionnaire included a demographic characteristics part, which included age, gender, marital status, educational level, total years of experience, years of experience in current hospital, years of experience in current unit, total weekly working hours and if participant worked in shifting programme. In addition, it included some situation-related characteristics such as the number of beds in the current hospital, the number of beds in the working unit, the type of hospital, if participant work according to evidence-based practice and if hospital consider patient safety as a top priority. In addition, two open-ended questions, whether or not participant trained for patient safety, and what are the most important three things to improve patient safety were included. Regarding the reliability of instruments, the HSOPSC survey was utilized in numerous countries including the United States, Canada and Belgium, and translated to different languages such as Taiwanese, Turkish and Arabic. The reliability measured by Cronbach’s coefficient alpha of the original English version ranged between 0.63 and 0.84 (Sorra & Dyer 2010; Sorra &
Patient safety culture
Nieva 2004), whereas for the Arabic version, it ranged between 0.45 and 0.81 (El-Jardali et al. 2010). In the current study, Cronbach’s coefficient alpha values ranged from 0.41 to 0.78. Ethical consideration
Formal approval from the institutional review board at the Jordan University of Science and Technology, Ministry of Health, and hospital administrators was attained. Consent forms were obtained from all participants. Full disclosure of the study’s purposes and significance was provided to all. Additionally, participants were assured that participation was voluntary. Furthermore, the acquired data will be kept both anonymous and confidential. In addition, approval to use the instrument was granted. Procedures and data collection
Once the IRB’s approval was obtained, a request to collect the data was sent to the Jordanian Ministry of Health (MOH), and the administrator of each private and university hospital attained approval for the distribution of the questionnaire. An envelope included a self-reported questionnaire, with a cover letter explaining the study purposes, outcomes and instructions were provided to the in-charge nurse by the researcher and her assistant to distribute the envelopes to eligible nurses at different units. Envelopes were given to the in-charge nurses in each unit at the beginning of the ‘A’ shift and returned in a timely manner, in the same day.
85
26 years (M = 7.5 years, SD = 5.377). The mean of nurses’ experience in their current working hospital was 6.37 years (SD = 5.129, R = 1–25), and the mean of nurses’ experience in their current working unit was 4.8 years (SD = 4.321, R = 1–22). Of the participants, 66.6% (n = 438) were working 8 h shift per day, while 33.4% (n = 220) worked more than 8 h per day. In addition, the mean of total weekly working hours was 46.91 h (SD = 3.54, R = 40–58). Participating nurses worked within different hospital sectors including governmental, university and private hospitals with a percentage of 66.9, 23.6 and 9.5%, respectively. For the unit/area of working, a total of 141 nurses (21.3%) worked in intensive care units (ICUs) (general ICU, paediatric ICU, neonatal ICU, cardiac ICU and coronary care unit). Other nurses worked at surgical, medical and emergency units with percentages of 16.6, 13.7 and 11.9%, respectively. Nurses worked in hospitals with less than 100 beds (21.9%, n = 144), between 100 and 300 beds (41%, n = 270) and more than 300 beds (37.1%, n = 244). For the hospital units’ bed, nurses worked in units with less than 20 beds (56.8%; n = 374), between 20 and 40 beds (32.1%; n = 211) and more than 40 beds (11.1%; n = 73). Although 46.7% (n = 307) of the respondents reported that they use evidencebased practice, the remaining 53.3% (n = 351) did not. Most of the nurses in Jordanian hospitals 81% (n = 533) stated that patients’ safety was a priority in their current working hospital. Furthermore, 76.6% (n = 503) of nurses received training on patient safety while 23.4% (n = 154) did not receive any training (see Table 1).
Data analysis plan
Descriptive statistic, frequencies and percentages according to the level of measurement were used. In addition, multivariate analysis – linear regression – was used to look at the factors that would influence patient safety culture in Jordanian hospitals.
Results Participants’ characteristics
A total of 797 participants were approached; however, 663 questionnaires were returned with a total response rate of 83.1%. Five questionnaires were excluded, either because they did not meet the inclusion criteria (four filled by practical nurses) or due to missing data. Therefore, the total number of participants was N = 658. Of all participants (N = 658), 59.9% (n = 394) were female RNs and 40.1% (n = 264) were male RNs. Nurses’ mean age was 30 years [standard deviation (SD) = 5.76, R = 22–55]. Most of nurses 87.1% (n = 573) hold a bachelor degree, whereas 8.5% (n = 56) hold a 3-year diploma and 4.4% (n = 29) of nurses hold a master degree. Nurses’ experience ranged between 1 and
© 2014 International Council of Nurses
How do nurses at Jordanian hospitals perceive patients’ safety culture?
Patient safety culture in Jordanian hospitals from nurses’ perspective was appraised by the composite frequency of each dimensions, and by verifying areas of strength and areas necessitating improvement, with respect to patients’ safety issues. The study results revealed that the composite frequencies ranged between 21 and 78.8%. The highest composite frequency of patient safety related to unit-level dimension was 79%, reflecting nurses’ positive perception of team work within the unit, while the lowest composite frequency (21%) means that only 21% of the nurse’s responses reflected positive opinion about the non-punitive response to errors. For hospital-level dimensions of patient safety, the highest composite frequency was related to nurses’ positive opinion of the management support for patients’ safety (53.5%). For the outcome variables, the highest composite frequency related to the frequency of reporting events (69.2%) (see Table 2). From the nurses’ perspective, the major areas needing improvement (percentage of items positive response
