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Azize Aydemir¹ and Zeliha Koç²

¹Giresun University, Health Science Faculty, Giresun, Türkiye. ²Health Science Faculty, Ondokuz Mayıs University, Samsun, Türkiye (Correspondence to: Zeliha Koç: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Abstract

Background: Nurses have a key role in ensuring the safety of patients, reducing the likelihood of errors and improving patient outcomes.

Aims: This study aimed to determine the factors affecting patient safety, with a focus on the culture and attitudes of nurses working in emergency units.

Method: This cross-sectional, descriptive, correlational study was conducted between 10 January and 30 August 2015 among 282 nurses who worked at emergency units of 19 hospitals in the north-central Black Sea Region of Türkiye Data were obtained using descriptive information forms, the Patient Safety Attitude Scale (PSAS) and the Patient Safety Culture Scale (PSCS).

Results: The mean total PSAS score was 152.26 [standard deviation (SD) 22.54; range 46–230], while the mean total PSCS score was 2.56 (SD 0.52; range 1–4). Around a quarter of the participants reported errors, such as medication errors and patient falls, which threatened patient safety in the emergency units. The case report forms were not filled when these errors occurred.

Conclusion: Attitude and culture of nurses in hospital emergency units towards patient safety differed according to their sociodemographic and work–life characteristics, including being satisfied with working in the emergency room, quality of work–life balance, level of job satisfaction, and number of years working in the emergency room.

Keywords: attitudes, culture, emergency unit, nurses, medication errors, patient safety, emergency care, Türkiye

Citation: Aydemir A; Koç Z. Patient safety culture and attitudes among emergency care unit nurses in Türkiye. East Mediterr Health J. 2023;29(3):195–204. https://doi.org/10.26719/emhj.23.026 Received: 31/03/22; accepted: 03/11/22

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

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Introduction

There is a growing interest in patient safety culture, as healthcare organizations undertake studies and promote practices to ensure patient safety (1). The World Health Organization defines patient safety as “the prevention of errors and adverse effects to patients associated with health care” and emphasizes the importance of safety by healthcare organizations (2). Patient safety encompasses all precautions taken by health organizations and healthcare professionals to prevent, report and analyse medical errors leading to adverse events during care and to eliminate or reduce the negative effects of such errors on patients accessing services (3).

In a healthcare organization, prevention of medical errors and elimination or reduction of the negative effects of such errors on patients depends upon having created a patient safety culture within the organization (4). Patient safety culture derives from the hypotheses, values and norms shared by team members, units or organizations which directly or indirectly affect patient safety (5). It specifies what is and what is not important within a healthcare organization, and determines behaviours relating to patient safety (6).

The work environment and working conditions of nurses are among the important factors that affect patient safety and culture (7). Findings indicate that nurses’ work environments pose a threat to patient safety (8), that heavy workloads and that low job satisfaction reduce the quality of care and services provided by nurses (9,10). Patients generally attend the emergency unit due to acute disease or injury which requires rapid treatment. Thus, nurses working in the emergency unit are occasionally obliged to initiate immediate treatment without obtaining detailed history from patients. Emergency unit nurses experience problems especially when the patient is unconscious and they are unable to obtain sufficient information on the patient’s medical condition (11,12).

In Türkiye, emergency units are highly stressful places. Health professionals working in the unit often fail to meet their own physiological needs, such as eating, due to insufficient personnel and heavy workloads. Patients’ relatives often insist that their relatives should receive medical attention before others without paying attention to triage. Such situations lead to a decreased tolerance for patients and their relatives as well as burnout and fatigue among emergency unit nurses (12). Nurses play key roles not only in patient care but also in informing systems that enable patient safety, reduce the possibility of errors and develop strategies to improve patient outcomes (6,13,14). Thus, it is important that healthcare institutions understand the attitudes and behaviours towards patient safety so they can determine the weak points, errors and other factors affecting them.

There have been a number of studies about patient safety culture and attitudes of healthcare professionals in other countries (15–19), but little is known about the factors that affect nurses’ attitudes towards patient safety in Türkiye (13,14,20,21). As far as we know, this study is the first to examine the factors affecting patient safety culture and the attitudes of nurses employed in the emergency units of hospitals in and around Samsun, a city located in the central Black Sea region of northern Türkiye.

To improve patient safety in emergency units, studies which analyse differences between nations, regions and cultures, and the findings and information obtained from these studies, are essential. Our findings will be useful in formulating appropriate strategies and national plans of action to improve patient safety in emergency units. Higher quality and more reliable care and treatment can be given when we know the factors affecting patient safety culture in emergency units and the attitudes of nurses who work in them. Therefore, answers were sought for the following questions:

What are the culture and attitudes regarding patient safety among nurses working in the emergency unit?

Do the sociodemographic or occupational characteristics of nurses affect their patient safety culture and attitudes in the emergency unit?

Methods

Study design and sampling method

This cross-sectional, descriptive, correlational study was conducted between 10 January 2015 and 30 August 2015 in 19 hospitals in Samsun, a city in the Black Sea Region of Türkiye. The sample size was determined as 238, at a 95% confidence interval and a 3% margin of error. The total number of nurses employed in the emergency units of the hospitals was 306. The nurses were selected using random sampling, a probability sampling method. To select the sample, a list was prepared containing numbers given to all nurses working in the emergency service of the hospitals. Nurses to be included in the sample were determined by drawing 238 numbers from the list. Considering that there may be data losses, the drawing was terminated at 282 (92.2%). The sample comprised nurses who had been employed in the emergency unit for at least 6 months.

There were no differences between the study hospitals (n = 19), all of which were general hospitals. Patients with various health problems and a stable condition, which only required outpatient treatment, could be admitted to emergency units as well as patients who had a potentially life-threatening condition (mainly trauma, injury due to accidents and critical patients). The number of nurses employed in the emergency units in this study ranged between 15 and 21 for each hospital.

Data collection

The data for this study were collected from the nurses using a survey form prepared by the researchers, the

Patient Safety Attitude Scale (PSAS) and the Patient Safety Culture Scale (PSCS). The survey form contained 21 questions, 4 of which covered the sociodemographic characteristics of the nurses. The following questions were asked to investigate nurses’ work-related characteristics:

What is your duty at the emergency unit (service nurse/supervising service nurse)?

How long have you been working as a nurse?

How many months have you been working at the emergency unit?

Your employment status at the hospital (staff/on contract)?

Do you love your profession? (I do/I do not/undecided)?

Are you satisfied with the service you work at (satisfied/not satisfied/partly satisfied)?

Type of employment (daytime/in shifts/other-specify)?

How many hours do you work per week?

Average number of patients cared for per day?

How would you evaluate your quality of work life? (perfect/very good/good/poor/very poor)?

How would you define your level of job satisfaction at the organization (very good/good/medium/partly poor/poor)?

Nurses were asked the following questions regarding patient safety:

Have you encountered a situation or event that threatened patient safety in the emergency room (yes/no)?

If your answer is yes, what were these situations or events that threatened patient safety?

When you encounter a medical error that threatened patient safety in the emergency service, did you report this situation (yes/no)?

Do you encounter medication errors in the emergency room (yes/no)?

If your answer is yes, what are the most common medication errors you encounter in the emergency department?

What do you think are the reasons for medication errors in the emergency service?

The survey forms were pilot-tested for ease of use and comprehensibility on a group of 8 nurses who were not included in the final sampling. Respondent nurses completed the survey form and the scales in a quiet room when they had less workload. The researchers provided them with information about the study and obtained their verbal informed consent. They were informed that they could decide not to participate in the study, that no identifying information would feature on the survey forms, and that the data would be used only for the study. Data collection lasted approximately 15–20 minutes.

Patient Safety Attitude Scale

The PSAS was developed by Sexton et al. (22) and adapted for the Turkish language by Baykal et al., adopting the group translation approach for testing the language validity of the original scale (23).

The Turkish version of the PSAS has 6 subdimensions and 46 items: job satisfaction (11 items), teamwork climate (12 items), safety climate (5 items), perception of management (7 items), stress recognition (5 items) and working conditions (6 items) (23). This 5-point Likert-type scale has the following response categories: 5 = I totally agree, 4 = I agree, 3 = I partially agree, 2 = I disagree, 1 = I totally disagree. Ten items (21, 36, 37, 38, 39, 40, 41, 42, 43, 45) are negatively scored. Total scores range between 46 and 230. The scale has no cutoff score. Higher scores indicate positive attitudes to patient safety while lower scores indicate negative attitudes (22). Cronbach’s alpha reliability coefficient for the PSAS was 0.93.

Patient Safety Culture Scale

The PSCS was developed by Turkmen et al (24). They generated an 83-item PSCS draft. To test content validity, the draft scale was evaluated by a panel of 10 professionals and the items were rewritten based on their opinions. The scale was pilot-tested among 15 people who had similar characteristics to the study sample to test its understandability. The item total score correlations ranged between 0.46 and 0.75. Items with low total score correlations (correlation coefficient of 0.30 and below) were excluded from the draft scale, resulting in a total of 51 items (24).

Confirmatory factor analysis was conducted to test construct validity. Factor loadings ranged between 0.43 and 0.82. The Pearson correlation analysis was carried out to assess the consistency between mean test–retest scale scores; the test–retest scores were statistically significantly correlated (r = 0.47, P < 0.001). Cronbach’s alpha for the scale was 0.97 (24).

The PSCS includes 5 dimensions: management and leadership (17 items), training of personnel (7 items), reporting unexpected errors and events (5 items), care environment (8 items), and personnel behaviour (14 items). The 4-point Likert type scale has the following response categories: 1 = I totally disagree, 2 = I disagree, 3 = I agree, 4 = I totally agree. Subscale scores are calculated by adding the subscale items and then dividing the sum by the number of items within the subscale. Total scores are calculated by adding the mean subscale scores and dividing the sum by 5, resulting in a total score between 1 and 4. The scale has no cutoff score. Scores approaching 4 indicate a positive patient safety culture, while scores approaching 1 indicate a negative patient safety culture (24). Cronbach’s alpha for the PSCS in this study was 0.97.

Ethical considerations

The study began only after consent had been received from the ethics committee of the Ondokuz Mayıs University (B.30.2.ODM.0.20.08/1129). Written consent to collect the data was received from the managers of the hospitals where the study was conducted as well as from the managers of the Ondokuz Mayıs University hospital. The nurses participating in the research provided their verbal informed consent.

Data analysis

The data were analysed using SPSS, version 22.0, software package. A normality test of the quantitative data was examined using Shapiro–Wilk. Multiple regression analysis was used to examine the effect of independent variables on scale scores. The backward method was used to include independent variables in the model. The significance level was set at P < 0.05. In the first stage, we incorporated into the model all independent/predictor variables (age, marital status, sex, education, position in the emergency service, years of employment in nursing, years of employment in the emergency service, status of employment in the hospital, whether they liked their job, whether they were satisfied with their work, type of employment, weekly working hours, number of patients cared for per day, quality of their life at work, degree of job satisfaction and the status of reporting medical errors). Subsequently, we removed predictor variables with the lowest partial F-value from the model one by one. We tested the contribution of the dropped variable each time. When the contribution of the dropped variable was statistically significant, the process of dropping the predictor variable was stopped and the model was given its final shape. In the analysis, categorical variables were given in terms of frequency (percentage) and quantitative variables were given as mean (+ standard deviation) and median (minimum–maximum).

Results

In total, 282 emergency nurses participated in this study. The mean age was 31.54 [standard deviation (SD) 7.31] years; 64.5% were female; 65.2% were married and 95.7% were staff nurses. Other demographic and working life characteristics are shown in Table 1.

Just under 25% of the participants said they had observed an error which threatened a patient’s safety in the emergency unit (drug malpractice, patient falling) (Table 2), but they did not fill out case report forms for the incidents. The most common drug malpractice incidents observed by the nurses were: delays in treatment time, 24.5%; not obtaining the drug allergy information for the patients, 21.6%; and wrong application, 12.1%. Regarding the reasons for drug malpractice, 32.6% of the nurses stated that they did not have sufficient information about the drug allergies of the patient, 31.6% stated that the number of patients per nurse was excessive and 24.1% stated that the working hours were too long.

The mean total PSAS score was 152.26 (SD 2.54), while the mean total PSCS score was 2.56 (SD 0.52) (Table 3). The regression model created to examine the independent variables affecting the PSAS total score was statistically significant (F = 8,248; P < 0.001). In the model, 30.5% of the independent and dependent variables were explained. As the nurses’ satisfaction with working in the emergency service increased, the PSAS score decreased by –4.855; as the work-life quality of nurses increased, the PSAS score decreased by –5.549; and as the job satisfaction level of nurses increased, the PSAS score decreased by –4.081 (Table 4).

The regression model created to examine the independent variables affecting the PSCS total score was statistically significant (F = 2.096; P = 0.008). In the model, 6.2% of the independent and dependent variables were explained. The PSCS score of the nurses decreased by –0.023 as years of employment in the emergency department increased (Table 5).

Discussion

This study was conducted because healthcare professionals, especially nurses, play an important

role in patient safety. This was the first study to determine and interpret factors affecting patient safety culture and the attitudes of nurses employed in emergency services of hospitals in the city of Samsun and its surrounding towns in the Middle Black Sea Region in northern Türkiye.

The characteristics of the nurses (age, sex, educational status, marital status, etc.) had no effect on their culture and attitudes regarding the safety of patients. However, as the number of years employed in the emergency department increased, the PSCS and PSAS scores decreased. Of course, the patient safety culture, attitudes and perceptions may differ according to the hospital, working environment and disciplines. In addition, according to previous research on this topic, health care professionals employed in emergency departments have worse perceptions of patient safety when compared with other services in a hospital (1,12,15,25–30).

The decline in the attitude of nurses regarding patient safety as the number of years working in emergency service increased may be due to the high number of patients using the emergency service, the low number of nurses working there, the attitudes and approaches of the institution managers and occupational burnout (13,14,25,31). Apart from the close relationship between service provision and burnout, working conditions, level of morale and unclear job descriptions of the nurses may also affect the decline in nurses' attitudes towards patient safety (32). Factors related to the patient/nurse ratio and work environment can also adversely affect patient safety outcomes. If policies and practices regarding human resources in the institution are weak and the number of employees and work motivation of the personnel is low, problems related to medical errors or patient safety may frequently be encountered (7,33).

Emergency services in hospitals are potentially risky areas, where patient safety is under threat and medical errors are more common (34). They are highly complex units with the highest patient load compared with other departments (35–38); the workload is uncontrolled and unpredictable (34,39,40). Doctors and nurses working in the emergency service are under intense physical and mental pressure (35,41), for instance, the time pressure is very high, and decisions are often made under pressure (40,41).

Previous research on this subject indicates that emergency departments provide services beyond their capacity (42); high workload and understaffing affect the performance of employees and delivery of safe care (34); and overcrowding, interruptions at work and undertaking multiple tasks contribute to medical errors (40). Since patient safety is the basic building block of high-quality healthcare services, effectively reducing medical errors depends on ensuring patient safety (3).

In this study, 23.4% of the nurses had encountered an error threatening patient safety in the emergency service. Although medical errors generally indicate the absence of a patient safety culture in the institution where the error is made (27), the relatively few studies on safety culture perception in Türkiye show that awareness of a safety culture has not yet been established in hospitals, that patient safety culture varies from institution to institution, and that patient safety-related precautions are taken to comply with standards only during accreditation by international accreditation institutions (13,14).

Even though the awareness of health professionals in public institutions and some private hospitals regarding this topic has increased in recent years, application has not reached the desired level, especially in public and university hospitals, because of factors such as the lack of qualified health professionals, excessive patient loads and insufficient physical infrastructure. Consequently, medical error rates in healthcare constitute an important source of worry for institution managers within the context of patient safety (6,13,14,25).

Accordingly, none of the nurses who participated in the study stated that they had filled in a case information form about errors that had threatened patient safety. Güneş et al. determined that 80.4% of nurses never reported errors and that the institutions where the participants were employed did not have any protocols or policies regarding error reporting (14). The unwillingness of nurses to report errors in our country can be due to a number of reasons, including the fear of public shaming by colleagues, being forced to admit errors in public and fear of ostracism or negative consequences to one’s career (14,31,43). However, because punishments are applied in many institutions regarding medical errors, health professionals avoid reporting medical errors and patient safety issues for fear of punishment and incrimination. This also prevents access to realistic data on patient safety risk factors (14,43).

The establishment of patient safety culture in an institution requires the reporting of medical errors and factors that threaten the safety of employees and patients. It requires that heath workers accept responsibility for patient safety within the framework of the philosophy and dynamics of the institution (27,31,43,44). The prevention of medical errors is only possible when we acknowledge errors and learn from them. Errors that are caused by the healthcare institution or system can be prevented only through reporting, whether they harm the patient or not (45). For this reason, applying a non-punitive approach in an institution would contribute to patient safety and ensure high error reporting rates, even if the event was not harmful (46).

Since they are in contact with patients 24/7, emergency service nurses play a significant role in ensuring that patients remain safe. Reducing risk factors that threaten patient safety in the emergency room, forming a systematic safety culture, and providing efficient and safe nursing care to patients are all dependent on nurses acknowledging these risk factors (15). In this context, it is thought that organizing training for nurses working in high-risk services such as the emergency room, operating rooms and intensive care units would improve patient safety culture among nurses (47).

Patient safety is a very important subject that aims to reduce medical error-related mortality and other negative health outcomes. Having a strong safety culture will help in learning from mistakes, improving patient safety and encouraging teamwork. Determining potential dangers and including employees as partners increases patient safety and prevents errors (46). Monitoring, reporting, analysing and improving events that threaten the safety of patients and employees, and providing diagnosis, treatment, care and other services without harming the patient is the basic responsibility of not only doctors and nurses but all healthcare professionals (31). Establishing a patient safety culture in health institutions would create an environment where errors, processes and system-related problems can be discussed openly and without fear of punishment, ensuring the success of patient safety efforts. Thus, health outcomes related to diagnosis, treatment and care would significantly improve (13,14,25).

Conclusion

Patient safety attitudes and the culture of emergency nurses differ according to their sociodemographic and work-life characteristics. Reporting of patient safety risk factors and medical errors by nurses should be encouraged. To reduce medical errors, a non-punitive institutional environment should be created where nurses can report medical errors freely, with procedures and protocols specifically for the emergency units. Continuous monitoring and evaluation in the healthcare system should be implemented to increase awareness of patient safety and promote open communication between institution managers and workers.

Acknowledgement

We extend our thanks to all the nurses who took part in this study.

Funding: None

Competing interests: None to declare.

Facteurs affectant la culture et les attitudes en matière de sécurité des patients parmi le personnel infirmier des unités d'urgence des hôpitaux en Türkiye

Résumé

Contexte : Le personnel infirmier joue un rôle essentiel pour garantir la sécurité des patients, réduire le risque d'erreurs et améliorer les résultats pour les patients.

Objectifs : La présente étude visait à déterminer les facteurs affectant la sécurité des patients, en mettant l'accent sur la culture et les attitudes des personnels infirmiers travaillant dans les unités d'urgence.

Méthodes :  Cette étude étude transversale, descriptive et corrélative a été menée entre le 10 janvier et le 30 août 2015 auprès de 282 personnels infirmiers qui travaillaient dans les unités d'urgence de 19 hôpitaux de la région du centre-nord de la mer Noire en Türkiye. Les données ont été collectées à l'aide de formulaires d'information descriptifs ainsi que des échelles relatives aux attitudes en matière de sécurité des patients et à la culture de la sécurité des patients.

Résultats : Le score total moyen de l'échelle relative aux attitudes en matière de sécurité des patients était de 152,26 [écart type (ET) 22,54 ; fourchette 46-230], tandis que le score total moyen de l'échelle relative à la culture de la sécurité des patients était de 2,56 (ET 0,52 ; fourchette 1-4). Environ un quart des participants ont signalé des erreurs, telles que des erreurs de médication et des chutes de patients, qui menaçaient la sécurité des patients dans les unités d'urgence. Les formulaires de déclaration de cas n'ont pas été remplis lorsque ces erreurs se sont produites.

Conclusion : L'attitude et la culture des personnels infirmiers dans les unités d'urgence des hôpitaux à l'égard de la sécurité des patients diffèrent en fonction de leurs caractéristiques sociodémographiques et professionnelles, y compris la satisfaction de travailler dans un service des urgences, la qualité de vie au travail, le degré de satisfaction au travail et le nombre d'années de travail dans les services d'urgence.

العوامل المؤثرة في ثقافة كادر التمريض وموقفه من سلامة المرضى في وحدات الطوارئ بالمستشفيات

عزيزة أيدمير، زليحة كوش

الخلاصة

الخلفية: يؤدي كادر التمريض دورًا رئيسيًّا في ضمان سلامة المرضى، والحد من احتمال وقوع الأخطاء، وتحسين نتائج المرضى.

الأهداف: هدفت هذه الدراسة إلى تحديد العوامل التي تؤثر على سلامة المرضى، مع التركيز على ثقافة كادر التمريض العامل في وحدات الطوارئ وموقفه.

طرق البحث: أُجريَت هذه الدراسة المقطعية الوصفية الارتباطية في المدة من 10 يناير/ كانون الثاني إلى 30 أغسطس/ آب 2015 على 282 ممرضًا وممرضة من العاملين في وحدات الطوارئ في 19 مستشفى في منطقة شمال وسط البحر الأسود بتركيا. وأُخذت البيانات باستخدام استمارات معلومات وصفية، ومقياس الموقف من سلامة المرضى، ومقياس ثقافة سلامة المرضى.

النتائج: كان متوسط إجمالي درجات مقياس الموقف من سلامة المرضى 152.26 [الانحراف المعياري 22.54؛ النطاق 46-230]، في حين كان متوسط إجمالي درجات مقياس ثقافة سلامة المرضى 2.56 [الانحراف المعياري 0.52؛ النطاق 1-4]. وأبلغ نحو رُبع المشاركين عن وقوع أخطاء، مثل أخطاء المداواة وسقوط المرضى من الأسِرَّة، بما يهدد سلامة المرضى في وحدات الطوارئ. ولم تُملأ استمارات الإبلاغ عن الحالة عند وقوع هذه الأخطاء.

الاستنتاجات: يختلف موقف كادر التمريض في وحدات الطوارئ بالمستشفيات وثقافته بشأن سلامة المرضى باختلاف خصائصه المتعلقة بالجوانب الاجتماعية والسكانية والحياة العملية، ويشمل ذلك رضا كادر التمريض عن العمل في غرفة الطوارئ، وجَودة الحياة العملية، ومستوى الرضا الوظيفي، وعدد سنوات العمل في غرفة الطوارئ.

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