The Gerontologist

© The Author 2011. Published by Oxford University Press on behalf of The Gerontological Society of America.
Vol. 51, No. 6, 739–749 All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
doi:10.1093/geront/gnr053 Advance Access publication on June 27, 2011

Organizational Climate Determinants of

Resident Safety Culture in Nursing Homes

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Judith E. Arnetz, PhD, MPH, PT,1,2,* Ludmila S. Zhdanova, PhD,3
Dalia Elsouhag, MD, MS,1 Peter Lichtenberg, PhD,4 Mark R. Luborsky, PhD,4
and Bengt B. Arnetz, MD, PhD, MPH1,2

1
Department of Family Medicine and Public Health Sciences, Wayne State University, Detroit, Michigan.
2
Department of Public Health and Caring Sciences, Uppsala University, Sweden.
3
Department of Psychology, Carleton University, Ottawa, Ontario, Canada.
4
Institute of Gerontology, Wayne State University, Detroit, Michigan.

*Address correspondence to Judith E. Arnetz, PhD, MPH, PT, Department of Family Medicine and Public Health Sciences, Wayne State University
School of Medicine, 3939 Woodward Ave, Detroit, MI 48201. E-mail: jarnetz@med.wayne.edu

Received January 14, 2011; Accepted April 13, 2011

Decision Editor: Rachel Pruchno, PhD

Purpose of the Study:  In recent years, there
has been an increasing focus on the role of safety
culture in preventing costly adverse events, such as
medication errors and falls, among nursing home res-
idents. However, little is known regarding critical
organizational determinants of a positive safety cul-
ture in nursing homes. The aim of this study was to
identify organizational climate predictors of specific
aspects of the staff-rated resident safety culture
(RSC) in a sample of nursing homes.  Design and
Methods:  Staff at 4 Michigan nursing homes
responded to a self-administered questionnaire
measuring organizational climate and RSC. Multiple
regression analyses were used to identify organiza-
tional climate factors that predicted the safety culture
dimensions nonpunitive response to mistakes, com-
munication about incidents, and compliance with
procedures.  Results:  The organizational climate
factors efficiency and work climate predicted non-
punitive response to mistakes (p < .001 for both
scales) and compliance with procedures (p < .05
and p < .001 respectively). Work stress was an
inverse predictor of compliance with procedures
(p < .05). Goal clarity was the only significant
predictor of communication about incidents
(p < .05).  Implications:  Efficiency, work climate,
work stress, and goal clarity are all malleable orga-
nizational factors that could feasibly be the focus of
interventions to improve RSC. Future studies will
examine whether these results can be replicated with
larger samples.
Key Words:  Long-term care, Work environment,
Quality of care
Introduction
Providing quality nursing home care for the fast-
growing segment of older people in society is
becoming a major public health priority. Despite
years of regulatory oversight (Scott-Cawiezell et al.,
2005), nursing home care is often characterized
by high workloads and staff turnover (Gruneir &
Mor, 2008), difficulties in recruiting new and com-
petent staff (R. Stone & Harahan, 2010), and
suboptimal quality of care (Castle & Ferguson,
2010; Institute of Medicine, 2001; Maas, Specht,
Buckwalter, Gittler, & Bechen, 2008). Taken
togeth­er, these factors have serious implications
for the health and safety of nursing home residents.
Patient safety culture, previously studied in hospi-
tals (Sorra & Nieva, 2004), is an emerging concept
in nursing homes (Handler, Castle, et al., 2006).
However, little is known regarding organizational
determinants of a positive safety culture in nursing
homes. This study focused on organizational mea-
sures, which are malleable and could potentially

Vol. 51, No. 6, 2011 739

be the object of future interventions aimed at
improving the safety, care, and health of nursing
home residents.
Challenges to Resident Safety in Nursing Homes
Approximately 1.6 million elderly and disabled
persons receive nursing home care in the United
States each year (Centers for Disease Control,
2009). As the aging population lives longer with
more medically complex chronic conditions (He,
Sengupta, Velkoff, & DeBarros, 2005), those
receiving care are often frail, with multiple illnesses
characterized by physical, cognitive, and sensory
impairments. Adverse events, such as medication
errors (Barker, Flynn, Pepper, Bates, & Mikeal,
2002; Hansen et al., 2006; Scott-Cawiezell et al.,
2007), falls (Kamel, 2005; Rubenstein, Josephson, &
Robbins, 1994), pressure ulcers (Berlowitz et al.,
2003; Saliba et al., 2003), and urinary tract infec-
tions (Kamel, 2005) are recognized as common
problems in nursing homes (Maas et al., 2008). Few
studies have compared the incidence of adverse
events in nursing homes with other health care facil-
ities, such as hospitals. However, it has been sug-
gested that the risk of adverse events may be higher
among nursing home residents due to the greater
number and severity of chronic comorbid condi-
tions (Handler, Wright, Ruby, & Hanlon, 2006).
Most direct care in nursing homes is provided by
certified nursing assistants or licensed practical
nurses that may lack the level of knowledge neces-
sary to care for the elderly residents (J. E. Arnetz &
Hasson, 2007; Bonner, Castle, Men, & Handler,
2009; Gruneir & Mor, 2008). Registered nurses are
fewer in number, and physicians are most often not
on site (Johnson, 2010), leaving many nursing
homes with limited access to more advanced medi-
cal expertise. Thus, keeping nursing home resi-
dents safe is clearly a major challenge, necessitating
the creation and maintenance of an effective safety
culture (Scott-Cawiezell et al., 2006).
Safety Culture
Patient safety culture describes the commitment
to safety that permeates a health care organiza-
tion. It encompasses an open atmosphere for
discussion of errors, process improvements, and
system issues without fear of reprisal (Dana-Farber
Cancer Institute, 2000). A culture of safety empha-
sizes open communication regarding adverse events
and strategies for preventing incident recurrence
740
(Gruneir & Mor, 2008). Research on patient safety
culture in hospitals has identified several key
measurement domains, including staffing, commu-
nication openness, nonpunitive response to error,
feedback and communication about errors, hand-
offs and transitions, management support for
patient safety, and organizational learning (Sorra &
Nieva, 2004). In surveys using similar domains,
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safety culture ratings among nursing home
staff (Handler, Castle, et al., 2006) and administra-
tors’ (Castle & Sonon, 2006) were significantly lower
compared with those of corresponding groups in
hospitals. In both hospital and nursing home set-
tings, a nonpunitive work environment and com-
munication about adverse events were identified
as key aspects of safety culture (Bonner, Castle,
Perera, & Handler, 2008). In adapting the hospital
safety culture survey (Sorra & Nieva, 2004) to
nursing homes (Handler, Castle, et al., 2006), addi-
tional dimensions were added, namely training
and skills, teamwork, and compliance with proce-
dures (Sorra, Franklin, & Streagle, 2008). Compli-
ance with procedures was considered especially
important because a strong safety culture had in
previous research been linked to compliance with
safe work practices (Handler, Wright, et al., 2006).
Based on the literature on safety culture in health
care settings, this paper focuses on a nonpunitive
response to mistakes, communication about inci-
dents, and compliance with procedures as three
key aspects of resident safety culture (RSC) in
nursing homes. Following is a brief description of
these constructs.
Nonpunitive Response to Mistakes and Communi-
cation About Incidents
The fear of reporting errors or safety issues
among nursing home staff has been identified as
one of the major barriers to quality improvement
in the nursing home industry today (Gruneir &
Mor, 2008; Scott-Cawiezell et al., 2006). In one
study, administrators from a nationally represen-
tative sample of nearly 2,800 nursing homes
reported mistakes significantly less frequently than
their hospital counterparts (Castle & Sonon,
2006). In a study of 26 Ohio nursing homes
(Hughes & Lapane, 2006), 8% of nurses and 9%
of nursing assistants avoided reporting mistakes,
whereas 27% of nurses and 22% of nursing assis-
tants felt they were being punished after filing an
incident report. This reluctance to report may in
part be due to the strict and punitive nature of
The Gerontologist
U.S. nursing home guidelines (Bonner et al., 2008;
Kapp, 2003). Nursing homes are governed by both
federal and state regulations, with strict require-
ments to report and correct adverse events. These
guidelines may make staff and nursing homes
reluctant to report incidents and errors for fear
that it might lead to unwanted attention from
regulatory authorities (Hughes & Lapane, 2006).
Conversely, research has shown that health care
staff are more likely to report adverse events in
nonpunitive environments. For example, a study
on patient violence toward staff in health care
settings, including long-term care, found a higher
likelihood of reporting violent incidents in care
facilities that discouraged blame and encouraged
patient and employee safety (J. E. Arnetz & Arnetz,
2000). In nursing homes, staff were more likely to
report resident falls in facilities with higher staff
ratings of the RSC (Bonner et al., 2009). Young-
berg (2008) suggests that health care comprised
complex work processes and that errors are virtually
inevitable. However, rather than blaming individ-
ual health care providers for errors, root causes
must be sought in organizational and work char-
acteristics, which are closely linked to attitudes
regarding blame and incident reporting (Youngberg,
2008). Thus, there is a need to identify specific
organizational climate characteristics of a non-
punitive response to mistakes that encourages open
reporting of errors and near-misses.
Compliance With Procedures
Adverse events in nursing homes are often pre-
ventable, and standard safety guidelines have been
developed to enhance resident safety (The Joint
Commission, 2010; van Gaal et al., 2009). How-
ever, research has shown generally low levels of
adherence (Saliba et al., 2003) and significant var-
iation among nursing homes regarding adherence
to guidelines, for example, in the case of pressure
ulcer care (Berlowitz et al., 2003; Saliba et al.,
2003). Adherence in these studies was measured
via staff self-report (Berlowitz et al., 2003) as well
as medical record review (Berlowitz et al., 2003;
Saliba et al., 2003). The barriers to compliance
with these procedural guidelines are not well
understood, although staffing shortages, a top–
down organizational structure, and the adversarial
regulatory environment have been suggested as
possible explanations (Gruneir & Mor, 2008).
Time restraints and lack of knowledge among
individual staff members may also be factors in
Vol. 51, No. 6, 2011 741
noncompliance of safety guidelines (Maas et al.,
2008). In nursing homes that emphasized innova-
tion and teamwork, staff were more likely to report
adhering to pressure ulcer clinical guidelines
(Berlowitz et al., 2003). Although there is a lack of
studies specifically examining the role of organiza-
tional factors in nursing home safety compliance,
the literature cited here suggests that such factors
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may affect staff compliance behavior.
Organizational Climate
Organizational climate is defined as “employees’
shared perceptions about the norms, including
decision making and collaboration,” that charac-
terize their workplace (P. W. Stone et al., 2007).
Within organizations, individual employees’ per-
ceptions of patient safety culture are believed to
influence collective safety behavior (Neal, Griffin, &
Hart, 2000). Despite a general shift in the study of
patient safety from a focus on individual-level
factors as a cause of poor patient safety to organi-
zational factors (Neal et al., 2000; Scott-Cawiezell
et al., 2006; Vogelsmeier, Scott-Cawiezell, Miller, &
Griffith, 2010), there is limited knowledge regard-
ing which specific aspects of the organizational
climate that may affect specific facets of safety
culture. A study in a single Australian hospital
found that general organizational climate was a
predictor of staff perceptions of work safety
(which the authors termed “safety climate”),
which was linked to safe work behaviors (Neal
et al., 2000). However, both organizational climate
and safety climate were aggregate measures, and
relationships between specific subscales were not
investigated.
Thus, although research suggests that there is
an association between organizational climate and
patient safety (Neal et al., 2000; Scott-Cawiezell
et al., 2005; P. W. Stone et al., 2007), knowledge
is lacking regarding specific organizational climate
determinants as these studies have used composite
measures of organizational climate. There is a need
to study the relationship between organizational
climate and patient safety culture in greater detail
in order to create a fact-based foundation for
improving the quality of nursing home care. Based
on previous research (Hughes & Lapane, 2006;
Neal et al., 2000; Scott-Cawiezell et al., 2005;
P. W. Stone et al., 2005), we theorized that the
patient safety culture—a facet of a health care
organization’s performance—is in part determined
by the organizational climate. The aim of this study
was to identify malleable aspects of organizational
climate that predict specific key factors of safety
culture in nursing homes, namely nonpunitive
response to mistakes, communication about inci-
dents, and compliance with procedures.
The Current Study
In the present study, we examined relationships
between specific aspects of organizational climate
and each of the outcomes of interest, respectively.
We operationalized organizational climate by using
nine distinct dimensions of leadership, participa-
tion, feedback, competence development, employ-
eeship (a measure of worker engagement), efficiency,
goals, work climate, and also work stress. These
nine dimensions were selected because they have
been previously associated with higher staff per-
ceptions of quality of care (Arnetz, 1999) and bet-
ter organizational productivity (Anderzen & Arnetz,
2005), both of which could feasibly be related to
safety culture. These dimensions have also been
previously validated among large groups of health
care workers (B. B. Arnetz & Blomkvist, 2007;
B. B. Arnetz, Lucas, & Arnetz, 2011), including
staff in nursing homes and home-based elderly
care (J. E. Arnetz & Hasson, 2007).
We hypothesized that all nine of the organiza-
tional climate dimensions would be associated
with at least one of the three resident safety out-
comes. Specifically, we expected that leadership,
participation, feedback, competence development,
and work climate would all be positively associated
with nonpunitive response to mistakes. We further
hypothesized that leadership, participation, employ-
eeship, and efficiency would be positively associ-
ated, and work stress negatively associated, with
communication about incidents. Finally, we expected
feedback, competence development, work climate,
and goal clarity to be positively associated with
compliance with procedures, with work stress
inversely related.
Methods
Setting and Participants
A purposeful convenience sample of four nursing
homes in Detroit, MI, participated in the question-
naire study between January and July of 2010.
Two of the nursing homes were run by the same
for-profit organization, whereas the other two
were both nonprofit church-related organizations.
All four nursing homes were located within a
742
40-mile radius of the city of Detroit. The facilities
had between 74 and 108 beds and between 120
and 200 employees.
Procedures and Data Collection
The questionnaire study was advertised before-
hand at each nursing home via informational posters.
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Surveys were distributed at each facility by two
members of the research team at designated time
periods over a two-day period in order to enable as
many staff as possible to participate. At all four
facilities, all categories of staff on all work shifts
were invited to participate. Data collection ses-
sions were held during work hours and were pre-
ceded by brief information sessions where staff
received both oral and written information about
the study. Those choosing to participate filled out
an anonymous paper questionnaire and were
compensated for their participation with a $10 gift
card (gift cards were not permitted at one of the
four facilities). Completed questionnaires were
returned directly to the researchers who adminis-
tered the survey.
Measures
Resident Safety Culture.—RSC was measured
with the Nursing Home Survey on Patient Safety
Culture (NHSPSC), a version of the Hospital
Survey on Patient Safety Culture (HSPSC) that
was adapted for nursing homes (Handler, Castle,
et al., 2006; Sorra et al., 2008). The adapted ques-
tionnaire was pilot tested among more than 5,000
staff in 40 nursing homes across the United States
and was found to have sound psychometric prop-
erties (Sorra et al., 2008). For a detailed comparison
of the HSPSC and NHSPSC surveys, see Castle,
Wagner, Perera, Ferguson, and Handler, 2011.
Psychometric testing of the NHSPSC has shown
acceptable validity and reliability (Castle et al., 2011).
The following RSC dimensions were utilized in
this study: nonpunitive response to mistakes,
feedback and communication about incidents, and
compliance with procedures. “Nonpunitive response
to mistakes” is a four-item factor measuring
nursing home staff’s perceptions of the workplace
atmosphere with regard to mistakes. A sample
item from this scale is “Staff are blamed when
a resident is harmed.” Internal reliability for the
scale, measured with Cronbach’s alpha, was .70.
“Feedback and communication about incidents”
comprised four items that concern the degree of
The Gerontologist
workplace discussion of adverse or potentially
harmful incidents. “Staff tell someone if they see
something that might hurt a resident,” is a sample
item from this scale, which had an alpha of .83.
The third variable, “Compliance with procedures,”
is three items that measure the degree to which
staff follow standard procedures at work. One
item in this scale is, “To make work easier, staff
often ignore procedures.” Cronbach’s alpha for
the scale was .54. All items use a 5-point response
scale (1 = strongly disagree; 5 = strongly agree) and
include an additional alternative for “Does not
apply or don’t know.” Scores for each RSC scale
were calculated for each respondent by summing
scores for component items and converting that
sum to a percentage of the maximum possible
score. Scale scores thus range between 0 and 100%.
A detailed description of all items in these RSC
scales is available in the Supplementary Appendix.
Organizational Climate.—The nursing home’s
organizational climate was measured with the
Quality-Work Competence (QWC) questionnaire
(B. B. Arnetz, 1997; Dunn, Arnetz, Christensen, &
Homer, 2007). The QWC has been previously val-
idated among large numbers of health care profes-
sionals and has good psychometric properties
(B. B. Arnetz, 1997; Anderzen & Arnetz, 2005;
J. E. Arnetz & Hasson, 2007; B. B. Arnetz et al.,
2011). Nine QWC dimensions were measured in
this study: leadership, participation, performance
feedback, competence development, employeeship,
efficiency, goal clarity, work climate, and work
stress. “Leadership” is a four-item scale measuring
staff perceptions of their immediate supervisor in
terms of communication, consistency, goal achieve-
ment, and workplace development and improve-
ment. A sample item is, “My immediate supervisor
communicates clearly.” Cronbach’s alpha for the
Leadership scale was .85. The “Participation”
scale comprised six items (Cronbach’s alpha .86)
measuring staff’s perceived influence over and
involvement in their work. A sample item includes,
“Are you able to influence decisions made at your
workplace?” “Performance feedback” comprised
three items that measure feedback received from
one’s immediate supervisor. A sample item is,
“Does your manager make clear what is expected
of you in your work?” Cronbach’s alpha for the
feedback scale in this study was .48. “Competence
Development” (Cronbach’s alpha .86) comprised
four items measuring the employee’s opportunities
Vol. 51, No. 6, 2011
to use and develop their skills at work. A sample
item is, “I feel that I develop at my work.”
“Employeeship” is a four-item scale (Cronbach’s
alpha .75) that reflects an employee’s attitudes
toward and responsibility for one’s work. A sam-
ple item is, “I take responsibility for keeping myself
informed.” “Efficiency” is a four-item measure of
the employee’s perception of how well work pro-
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cesses function at their workplace. “Resources are
optimally utilized” is a sample item from this scale,
which had an alpha of .89. The “Goals” scale
(Cronbach’s alpha .81) comprised four items
that summarize the clarity of the workplace goals.
A sample item is “The goals are well-defined.”
“Work climate” is three items measuring percep-
tions of social support and cohesion among one’s
colleagues. The alpha for work climate was .89.
“There is a pleasant atmosphere at my workplace”
is a sample item. Finally, “Work stress” is a four-
item scale (alpha .84) that focuses on staff percep-
tions of the adequacy of time available to do one’s
work well. A sample item is “Do you have time to
plan your work tasks ahead of time?”
All QWC items use a 4-point Likert-type
response scale (e.g., 1 = disagree strongly; 4 = agree
strongly). Scores for each scale were calculated
according to the same methods used in calculating
RSC scale scores and also range between 0 and
100%. Higher values indicate more positive staff
ratings for all scales except work stress, where
lower values are more desirable, indicating lower
levels of stress. A detailed description of all items
in these organizational climate scales is available
in the Supplementary Appendix.
Statistical Analyses
Bivariate analysis was used to examine correla-
tions for all 12 variables of interest (9 QWC pre-
dictor and 3 RSC outcome variables) in the study.
Multiple regression analyses were conducted on
nonpunitive response to mistakes, feedback and
communication about incidents, and compliance
with procedures, respectively. In each analysis,
all nine predictor variables were entered simulta-
neously. Due to the low alpha value for the organi-
zational climate measure for feedback, all three
regressions were also run excluding that inde-
pendent variable, yielding identical results. Thus,
reported results include all hypothesized predic-
tors. For all regression analyses, variance inflation
factor values were less than 3.0, indicating that
743
collinearity was not a concern (Neter, Kutner, Table 1.  Characteristics of Questionnaire Respondents
(n = 312)
Nachtsheim, & Wasserman, 1996).
Intracluster correlation coefficients (ICC) were
n %
calculated to measure how much of the total vari-
ance in each outcome variable was accounted for by Job category
  Nursing assistant/aide 117 40
group membership, that is, nursing home (Cohen,   Support staff 52 18
Cohen, West, & Aiken, 2003). ICCs range from 0   Administrator/manager 40 14
(complete independence) to 1 (complete depen-   Direct care staffa

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33 11
dence). ICCs of .05 or less do not pose a threat to   Licensed nurse 27 9
the analyses, whereas ICCs of greater than .05   Administrative support staff 25 8
  Otherb 1 <1
indicate that clustering effects should be taken
Length of employment at current nursing home
into account (Thomas & Heck, 2001). The ICCs   Less than 2 months 10 3
for communication about incidents and compli-   2–11 months 53 18
ance with procedures were equal to .03 and .04,   1–2 years 52 17
respectively; thus, interdependence did not pose a   3–5 years 81 27
problem for those regression analyses. The ICC   6–10 years 59 20
  11 years or more 45 15
for nonpunitive response was .06, which is slightly Hours worked per week
above the .05 cutoff. For this reason, a .01 alpha   15 or fewer 9 3
level was chosen for the regression analyses with   16–24 27 9
this dependent variable (Thomas & Heck, 2001).   25–40 198 66
For all other analyses, statistical significance was   More than 40 68 22
Shift
set at p < .05 (two-tailed). The statistical package
  Days 196 66
SPSS (version 18.0) was used for all analyses.   Evenings 69 23
Approval for this study was granted by the   Nights 34 11
Human Investigation Committee at Wayne State
Notes: aExamples of direct care staff: activities staff
University, Detroit, MI. member, dietician/nutritionist, physical therapist, and social
worker.
Results b
This alternative was marked but left blank.
A total of 312 staff from the four nursing homes
responded to the questionnaire, with an overall Table 3 resents the results of the respective
response rate of 64%. The percentage of missing multiple regressions with nonpunitive response,
values was under 3% for all individual items, with communication about incidents, and compliance
the exception of background questions, where with procedures as the dependent variables. The
missing values ranged from 3.2% to 5.4%. organizational climate measures efficiency and
Characteristics of questionnaire respondents are work climate were the only significant predictors
summarized in Table 1. Nursing aides comprised of nonpunitive response to mistakes, explaining
the largest group of respondents (40%), followed 38% of the total variance. The goal clarity dimen-
by support staff (e.g., maintenance, food service/ sion was the only significant predictor of commu-
dietary, housekeeping, 18%). More than 70% of nication about incidents, explaining 28% of the
respondents (n = 211) worked directly with resi- total variance. Finally, the organizational climate
dents most of the time, and slightly more than dimensions efficiency and work climate emerged as
10% (n = 34) were paid by staffing agencies. The significant positive predictors, and work stress
majority of respondents (62%) had worked 3 years was a significant negative predictor of compliance
or longer at their current nursing home. Among with procedures. Together, these three variables
those employed by staffing agencies, the majority explained 28% of the variance in compliance with
(71%) had worked 1 year or longer. procedures.
Table 2 presents bivariate correlations and
descriptive statistics for the variables included in
the study. All predictors were strongly and moder- Discussion
ately related with all criterion variables, with cor- The aim of this study was to identify organiza-
relation coefficients ranging from 0.15 to 0.53. As tional climate predictors of three key aspects of the
expected, work stress was inversely associated RSC in nursing homes. We hypothesized that all nine
with all other variables. of the organizational climate dimensions would

744 The Gerontologist

 Table 2.  Means, Standard Deviations, and Bivariate Associations Between Safety Culture (1–3) and Organizational
Climate (4–12) Measures

M SD 1 2 3 4 5 6 7 8 9 10 11 12
1 Nonpunitive response 57.22 19.74 1
2 Communication about 87.71 15.3 0.41 1
  incidents
3 Compliance with 63.02 18.92 0.45 0.37 1

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  procedures
4 Leadership 75.34 20.66 0.40 0.35 0.34 1
5 Participation 78.21 19.50 0.40 0.35 0.29 0.54 1
6 Feedback 82.32 16.27 0.38 0.35 0.31 0.69 0.48 1
7 Competence Development 84.83 18.16 0.36 0.31 0.28 0.49 0.53 0.48 1
8 Employeeship 82.38 14.46 0.21 0.27 0.15 0.45 0.52 0.35 0.39 1
9 Efficiency 71.28 20.32 0.53 0.38 0.42 0.64 0.53 0.51 0.44 0.40 1
10 Goals 79.44 18.18 0.39 0.45 0.34 0.57 0.55 0.60 0.47 0.37 0.56 1
11 Work climate 74.59 21.55 0.49 0.26 0.43 0.50 0.34 0.39 0.35 0.22 0.53 0.40 1
12 Work stress 26.70 21.66 −0.36 −0.23 −0.34 −0.44 −0.55 −0.37 −0.46 −0.38 −0.43 −0.54 −0.33 1
Note: N = 312. All correlation coefficients are significant at p < .001.

predict at least one of the safety culture outcomes.
However, only four of the nine dimensions—
efficiency, work climate, goal clarity, and work
stress—emerged as significant predictors.
With regard to nonpunitive response to mistakes,
our hypothesis was only confirmed with regard to
the work climate predictor. None of the other
hypothesized dimensions—leadership, participa-
tion, feedback, or competence development—were
significant predictors of this aspect of RSC. Our
prediction that feedback and communication
about incidents would be positively associated
with leadership, participation, employeeship, and
efficiency and negatively associated with work
stress was also not confirmed. Instead, only a single
organizational climate factor, goal clarity, was a
significant predictor of communication about inci-
dents. Finally, our hypothesis regarding compli-
ance with procedures was partially confirmed in
that work stress was a significant inverse predic-
tor. No significant association was seen with the
other predicted variables.
Three of the four organizational climate
variables—efficiency, work climate, and work
stress—were significant predictors of compliance
with procedures, and efficiency and work climate
were also significant determinants of nonpunitive
response to mistakes. The efficiency subscale mea-
sures staff perceptions of the degree to which staff
plan the work at one’s workplace; everyone works
toward a common goal; the decision-making
process works well; and whether resources are
optimally utilized. Work climate measures how
well staff get along at the workplace; whether there
is a pleasant atmosphere at work; and whether
colleagues are supportive of one another. Together,
these two factors explained 38% of the total vari-
ance in nonpunitive response, indicating that when
work processes operate smoothly and staff work
well together, the culture of blame is less strong.
These same factors, along with less work stress,
explained 28% of the variance in compliance with
procedures. The work stress subscale measures to
what degree one has enough time to plan, carry
out, reflect over, and consider ways to improve
work tasks. Thus, based on these results, staff
would be more likely to follow standard safety
procedures in nursing homes they judge to be effi-
cient, with pleasant and supportive colleagues and
with adequate time to carry out work tasks. These
results partly support those of Neal and colleagues
(2000), who found that general organizational
climate influenced reports of individual safety
behavior, including compliance with safety regula-
tions and procedures, in hospital employees. Previ-
ous studies have noted the importance of a positive
work climate for nursing home performance,
reporting that higher performing nursing homes
were characterized by more positive and cohesive
relationships (Scott-Cawiezell et al., 2005) and
better “connectivity” (Forbes-Thompson, Leiker,
& Bleich, 2007) among staff, compared with low-
performance facilities. However, neither of these
studies examined safety culture or safety perfor-
mance, specifically.
Few previous studies have examined staff per-
ceptions of work efficiency in nursing homes. In
a qualitative study of 30 nurse’s aides in nursing

Vol. 51, No. 6, 2011 745

 Table 3.  Multiple Regression Analysis Predicting group ratings of these constructs were not mea-
Nonpunitive Response to Mistakes, Communication About
Incidents, and Compliance With Procedures
sured. In another qualitative study of four nursing
homes, Forbes-Thompson and colleagues (2007)
Variable R2 B SE B b reported that staff found positive and creative
ways of getting their work done and meeting resi-
DV: nonpunitive response to mistakes
  Model 0.38*** dent needs in two high-performing nursing homes;
  Leadership −0.06 0.09 −0.07 in two low-performing nursing homes, staff tended
  Participation 0.08 0.08 0.08 to work in isolation, and staff relationships were

Downloaded from https://academic.oup.com/gerontologist/article/51/6/739/818625 by Universidade Federal da Santa Maria user on 20 June 2022
  Feedback 0.07 0.11 0.06 fragmented. Again, perceptions of efficiency per se
  Competence 0.07 0.08 0.06 were not measured.
   development
  Employeeship −0.11 0.10 −0.08
Work stress—measured in terms of the ade-
  Efficiency 0.31*** 0.08 0.31*** quacy of time to do one’s work—was an inverse
  Goals 0.02 0.09 0.01 predictor of compliance with procedures as we
  Work climate 0.28*** 0.06 0.30*** had predicted. Even in other industries, employees
  Work stress −0.08 0.07 −0.08 often use short cuts to complete tasks when there
DV: communication about incidents
is pressure for production, which often compro-
  Model 0.28***
  Leadership −0.01 0.07 −0.01 mises safety (Hansez & Chmiel, 2010). Nursing
  Participation 0.08 0.07 0.10 homes working understaffed, with large work-
  Feedback 0.03 0.08 0.03 loads per care giver, are pressured to perform
  Competence 0.12 0.07 0.14 scheduled duties with tight deadlines, which may
   development result in caregiver stress and safety violations
  Employeeship 0.04 0.08 0.04
  Efficiency 0.09 0.07 0.12
(Maas et al., 2008; Pekkarinen, Sinervo, Perala, &
  Goals 0.24*** 0.07 0.29** Elovainio, 2004).
  Work climate 0.06 0.05 0.08 Goal clarity was the only predictor of commu-
  Work stress 0.09 0.06 0.13 nication about incidents. Communication about
DV: compliance with procedures incidents refers to the organization’s actions when
  Model 0.28***
staff report possible harm to a resident, discussions
  Leadership 0.03 0.09 0.03
  Participation −0.04 0.08 −0.04 of ways to avoid reoccurrence of adverse incidents,
  Feedback 0.04 0.10 0.03 staff’s reporting of possible harm to re­sidents,
  Competence 0.05 0.08 0.04 and the degree of discussion about how to keep
   development residents safe. Previous studies have reported
  Employeeship −0.06 0.09 −0.05 associations between communication and both
  Efficiency 0.21** 0.08 0.22**
  Goals −0.02 0.09 −0.02
turnover (Anderson, Corazzini, & McDaniel,
  Work climate 0.25*** 0.06 0.27*** 2004) and work satisfaction (Scott-Cawiezell et al.,
  Work stress −0.15** 0.07 −0.17* 2004) among nursing home staff. However, few
Notes: B = unstandardized beta; b = standardized beta;
studies have explored the relationship between
DV = dependent variable. communication and organizational goals. Forbes-
*p < .05. **p < .01. ***p < .001. Thompson and colleagues (2007) reported that a
strong, coherent organizational mission was asso-
ciated with both positive staff relationships and
homes, Bowers and Becker (1992) found that aides information flow in two high-performing nursing
often increased their own work efficiency by homes. Staff perceptions of the organization’s
developing individual strategies for taking care goals were not specifically measured, however. In
of residents. These strategies often entailed cutting another qualitative study, facilitators to positive
corners and breaking rules by not following rou- organizational culture change in nursing homes
tine procedures. Although these strategies were a included shared values and goals at the facility
means of decreasing work stress, they usually level (Scalzi, Evans, Barstow, & Hostvedt, 2006).
required neglecting resident needs in some way, Shared values and goals were accomplished through
with negative repercussions for resident safety and open communication between management and
care quality. Thus, work efficiency in that study staff, which was considered key to creative problem
was inversely related to both work stress and com- solving and thus to organizational change. These
pliance with procedures. However, both efficiency findings, in line with our results, suggest that
and stress were defined by the individual, and when the goals of the organization are shared and

746 The Gerontologist

clearly communicated, staff will feel responsible
for achieving them. Thus, clarity of organizational
goals may be an important factor in nursing home
staff’s willingness to communicate about possible
harmful situations as well as to devise strategies
for how they can be avoided. Open reporting of
adverse incidents and medical errors in a nonpuni-
tive environment is a prerequisite for increasing
staff knowledge and awareness of factors and cir-
cumstances that can jeopardize patient safety
(Kapp, 2003; Scott-Cawiezell et al., 2006).
Limitations
The results of this study were based on ques-
tionnaire responses from staff at four nursing
homes in one geographic area and are not neces-
sarily generalizable to all nursing homes. In addi-
tion, our results are based on a convenience sample
of nursing homes and may not be representative of
others within this geographic region. The overall
response rate was 64%, and it is not known
whether respondents were truly representative of
all employees at the respective nursing homes.
Moreover, the questionnaire did not ask about
level of education or language ability, and it is pos-
sible that our response population was a selection
of those with capability of responding to a fairly
lengthy questionnaire offered only in English. How-
ever, the percentage of missing values was quite
low in this study, indicating that most respondents
understood and were willing and able to answer
most of the survey questions. Nevertheless, future
studies in larger more diverse samples are war-
ranted. Furthermore, the study was cross-sectional
in design and cause and effect cannot be deter-
mined. Results for both organizational climate and
RSC dimensions were based on self-reports, with a
risk for common method variance (Doty & Glick,
1998). Future studies should be prospective and
employ mixed methods, combining questionnaire
surveys with interviews, observations, and other
qualitative methods that may validate quantitative
findings. Such studies would enable the assessment
of actual responses to reported mistakes, commu-
nication practices about incidents, and compliance
with procedures and would complement the sub-
jective ratings reported here. Prospective studies
would also make it possible to study the ability of
staff-rated scores of organizational climate and
RSC to predict clinical resident outcomes, mea-
sured by the prevalence of adverse events, such as
medication errors, falls, and pressure ulcers.
Vol. 51, No. 6, 2011
Despite this study’s limitations, the methodo-
logical shortcomings are not sufficient to explain
the fact that our hypotheses were only partially
confirmed. This study, among the first to examine
organizational climate predictors of specific safety
culture outcomes in nursing homes, has pinpointed
four distinct factors as significant determinants.
The next step will be to see whether these factors
Downloaded from https://academic.oup.com/gerontologist/article/51/6/739/818625 by Universidade Federal da Santa Maria user on 20 June 2022
can be confirmed as predictors, and the other fac-
tors can be confirmed as nonpredictors, in future
studies.
Conclusions
Although previous studies have suggested a
relationship between organizational climate, per-
ceptions of work safety, and safety outcomes (Neal
et al., 2000; Scott-Cawiezell et al., 2005; P. W.
Stone et al., 2007), this study is, to the best of our
knowledge, the first to identify specific organiza-
tional climate determinants of specific safety cul-
ture outcomes in nursing homes. Although previous
research has shown that safety culture may be
affected by individual behavior, especially in terms
of compliance with procedures (Neal et al., 2000),
our results suggest that specific organizational
largely malleable characteristics are stronger pre-
dictors. These results suggest that changes toward
a culture of safety in nursing homes need to be on
an organizational level, which has been previously
suggested (Bowers & Becker, 1992; Buerhaus,
2004; Gruneir & Mor, 2008). Clear organiza-
tional goals, a focus on efficient work processes,
a positive work climate, and manageable levels
of stress may be key ingredients in nursing home
safety culture.
Supplementary Material
Supplementary material can be found at: http://gerontologist.oxford
journals.org.
Funding
This work was supported by Blue Cross Blue Shield of Michigan Foun-
dation, grant number 1547.II, Judith E. Arnetz, Principal Investigator.
Acknowledgments
The authors would like to extend their sincere thanks to the staff and
management at all participating nursing homes.The QWC survey instru-
ment is owned and marketed by the Swedish company Springlife AB.
Dr. B. B. Arnetz is the cofounder and co-owner of this company.
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