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BMJ Open Qual: first published as 10.1136/bmjoq-2023-002310 on 10 October 2023. Downloaded from http://bmjopenquality.bmj.com/ on October 10, 2023 at UFC - Universidade Federal
To cite: Carvalho REFL,
Bates DW, Syrowatka A, et al.
Factors determining safety
culture in hospitals: a scoping
review. BMJ Open Quality
2023;12:e002310. doi:10.1136/
bmjoq-2023-002310
► Additional supplemental
material is published online only.
To view, please visit the journal
online (http://​dx.d​ oi.​org/​10.​
1136/b​ mjoq-​2023-0​ 02310).
Received 9 February 2023
Accepted 9 September 2023
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1
Health Sciences Centre,
Universidade Estadual do Ceará,
Fortaleza, Brazil
2 Conclusion The instruments presented elements that
General Internal Medicine and
Primary Care, Brigham and
Women's Hospital, Boston,
Massachusetts, USA
3
General Internal Medicine
and Primary Care, Brigham
and Women's Hospital
Department of Medicine, Boston,
Massachusetts, USA
4
Health Sciences Centre,
Universidade Estadual do Ceara,
Fortaleza, Ceará, Brazil
5
Health Sciences Centre,
Universidade Estadual do Ceara
- Campus do Itaperi, Fortaleza,
Ceará, Brazil
Correspondence to
Dr Rhanna Emanuela Fontenele
Lima de Carvalho;
​rhanna.​lima@​uece.​br
Factors determining safety culture in
hospitals: a scoping review
Rhanna Emanuela Fontenele Lima de Carvalho ‍ ‍,1 David W Bates,2
Ania Syrowatka,3 Italo Almeida,4 Luana Sousa,5 Jaira Goncalves,5 Natalia Oliveira,5
Milena Gama,5 Ana Paula Alencar5
ABSTRACT
Objective To evaluate and synthesise the factors
determining patient safety culture in hospitals.
Methods The scoping review protocol was based on the
criteria of the Joanna Briggs Institute. Eligibility criteria
were as follows: (1) empirical study published in a peer-­
reviewed journal; (2) used methods or tools to assess,
study or measure safety culture or climate; (3) data
collected in the hospital setting and (4) studies published
in English. Relevant literature was located using PubMed,
CINAHL, Web of Science and PsycINFO databases.
Quantitative and qualitative analyses were performed
using RStudio and the R interface for multidimensional
analysis of texts and questionnaires (IRaMuTeQ).
Results A total of 248 primary studies were included. The
most used instruments for assessing safety culture were
the Hospital Survey on Patient Safety Culture (n=104) and
the Safety Attitudes Questionnaire (n=63). The Maslach
Burnout Inventory (n=13) and Culture Assessment
Scales based on patient perception (n=9) were used in
association with cultural instruments. Sixty-­six articles
were included in the qualitative analysis. In word cloud
and similarity analyses, the words ‘communication’
and ‘leadership’ were most prominent. Regarding the
descending hierarchical classification analysis, the content
was categorised into two main classes, one of which was
subdivided into five subclasses: class 1a: job satisfaction
and leadership (15.56%), class 1b: error response
(22.22%), class 1c: psychological and empowerment
nurses (20.00%), class 1d: trust culture (22.22%) and
class 2: innovation worker (20.00%).
remained indispensable for assessing the safety culture,
such as leadership commitment, open communication
and learning from mistakes. There was also a tendency
for research to assess patient and family engagement,
psychological safety, nurses’ engagement in decision-­
making and innovation.
INTRODUCTION
The Global Plan of Action for Patient Safety
2021–2030 (GPAPS), published by the WHO,
alerts managers, professionals and patients
to the importance of health institutions to
strengthen policies and strategies based on
science and patient experience, with the
objective of eliminating risks and preventable
harm to patients and health professionals.1
Carvalho REFL, et al. BMJ Open Quality 2023;12:e002310. doi:10.1136/bmjoq-2023-002310
Systematic review
WHAT IS ALREADY KNOWN ON THIS TOPIC
⇒ The evaluation of safety culture through question-
naires is an important practice in assessing the
quality of care provided to patients; however, the
literature has shown that these instruments do not
broadly consider the construct of patient safety cul-
ture. Thus, this review was developed to identify the
most evaluated constructs.
WHAT THIS STUDY ADDS
⇒ The concepts identified in the assessment of safe-
ty culture can be divided into organisational, pro-
fessional, and patient and family participation.
do Ceara. Protected by copyright.
However, these three dimensions were not identified
by using the same instrument. Thus, this research
can serve for the development and refinement of
safety culture instruments addressing constructs
aligned to research in the areas and principles out-
lined in the WHO’s Global Plan of Action for Patient
Safety 2021–2030.
HOW THIS STUDY MIGHT AFFECT RESEARCH,
PRACTICE OR POLICY
⇒ Leaders, organisations and health professionals
about the importance of patient and family partic-
ipation in patient safety.
⇒ Rethink the most widely used instruments for the
assessment of safety culture.
⇒ Consider the inclusion of constructs related to pro-
fessionals and the inclusion of the patient and family
in the instruments of evaluation of culture.
⇒ Foster the inclusion of the patient and family in their
own safety.
⇒ Encourage quantitative and qualitative analyses in
the literature.
In this document, GPAPS describes seven
principles for guiding the development and
implementation of the actions proposed in
the global action plan. One of these princi-
ples is the recommendation of managers to
assess patient safety culture. According to the
document, a strong safety culture is not only
essential to reduce harm to the patient but is
also crucial for providing a safe work environ-
ment for health professionals.1
Additional studies have found benefits of a
positive safety culture in health institutions.
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The relevance of a positive culture can be observed in
the quality of care provided to the patient, reduction in
the number of adverse events, length of hospital stay and
mortality, in addition to improving the satisfaction and
reduction of stress among professionals.2 3
In the literature, the terms ‘safety culture’ and ‘safety
climate’ are used synonymously, although they differ
from a conceptual and methodological standpoint. The
safety climate is conceptualised as the ‘measurable part’
of culture, the most superficial and visible, based on the
attitudes and perceptions of individuals.4 In this study,
the term ‘patient safety culture’ is the product of values,
attitudes, perceptions, competencies and behavioural
patterns of groups and individuals that determine
commitment, style and proficiency in managing patient
safety in health services,5 as it aligns with the perspective
of organisational culture theory and is the most used
term in the health context.
Before implementing any action that promotes a safety
culture in an institution, it must first be evaluated and
understood. Each institution is encouraged to find the
best way to assess its safety culture, considering its vision,
mission and objectives. However, measuring the safety
culture in health institutions using scales is an important
tool for assessing the quality of care provided to patients
and can be performed before and after the implementa-
tion of interventions, such as staff training and activities
that can minimise the stress of professionals.
To obtain reliable patient safety culture results through
questionnaires, researchers must be sure of the validity
and reliability of the instruments used in their applica-
tion. In recent decades, several instruments have been
developed to assess patient safety culture. There are those
that are exclusive for application in hospital institutions,
others in out-­of-­hospital environments and instruments
that can be used in any context. In the study, 139 publi-
cations were identified using 12 different questionnaires
as measurement instruments. The most used were the
Hospital Survey on Patient Safety Culture (HSOPSC),
Safety Attitudes Questionnaire (SAQ), Patient Safety
Culture in Healthcare Organisations Survey and the
Modified Stanford Patient Safety Culture Survey Instru-
ment. It should be noted, however, that among these,
there was a predominance of the use of the HSOPSC and
SAQ to measure patient safety culture.6
The instruments available for this assessment often do
not broadly include the construct of culture of patient
safety, although some elements remain indispensable,
such as leadership commitment, transparency, open and
respectful communication, learning from mistakes and
best practices, and a careful balance between a policy of
non-­blaming and accountability.7
The gap with these systematic reviews is the limited
number of articles that discuss the determinants of safety
culture in hospital institutions. Classic studies such as
those by Zohar,8 Guldenmund9 and Cooper,10 which
carried out revisions to the definition of safety culture,
cannot keep up with progress and current needs.
2 Carvalho REFL, et al. BMJ Open Quality 2023;12:e002310. doi:10.1136/bmjoq-2023-002310
BMJ Open Qual: first published as 10.1136/bmjoq-2023-002310 on 10 October 2023. Downloaded from http://bmjopenquality.bmj.com/ on October 10, 2023 at UFC - Universidade Federal
There are reviews based on instruments for safety
culture evaluation.11 12 In view of the evolution of the
global movement for patient safety recently published
by the WHO in the GPAPS 2021–2030, there is a need
for reassessment of the factors that can determine the
patient safety culture in healthcare institutions. Based
on this need to identify scientifically proven concepts
that determine the safety culture, this scoping review was
developed.
A preliminary review was performed in March 2022
in PROSPERO, MEDLINE, the Cochrane Database of
Systematic Reviews and Joanna Briggs Institute (JBI)
Evidence Synthesis. Fifty-­ nine systematic reviews were
identified in PROSPERO and 12 in JBI Evidence Synthesis,
all referring to safety culture interventions. No reviews
on factors constituting the safety culture were identified.
The objective of this scoping review was to evaluate and
synthesise the factors determining patient safety culture
in hospitals.
METHODS
This scoping review was conducted based on the criteria
outlined by the JBI Scoping Review Methodology Group
do Ceara. Protected by copyright.
and is reported in accordance with the Preferred Reporting
Items for Systematic Reviews and Meta-­Analyses extension
for Scoping Reviews checklist.13 14 Scoping reviews aim to
identify and map the breadth of evidence available on
a particular topic, often irrespective of source, whereas
systematic reviews aim to answer a specific research ques-
tion by identifying, appraising and synthesising primary
studies using a rigorous methodology. They clarify key
concepts in the literature and identify key characteristics
related to a concept, including those related to method-
ological research.15 The review protocol was registered
on Open Science Framework (OSF) (doi: 10.17605/OSF.
IO/VTB84). OSF is an open source, free software project
that facilitates open collaboration in scientific research.16
The search question was developed using the JBI PCC
(Population, Concept and Context) framework. We did
not consider a specific population. The concept was the
safety culture/safety climate, and the context was the
hospital setting. Our scoping review question was: What
are the factors determining the culture/patient safety
climate in hospitals?
We searched for empirical studies published in peer-­
reviewed journals that reported on methods or tools
used to assess, study or measure safety culture or climate,
where data were collected for the hospital setting, and
the papers were published in the English language. Arti-
cles on cross-­ cultural adaptation, those that evaluated
constructs other than safety climate or culture, and those
that did not clarify the assessment method were excluded.
The review followed the three steps recommended
by JBI. The first step was a search of the PubMed and
CINAHL databases. In this initial search, an analysis was
performed of the text words contained in the titles and
abstracts of the retrieved articles and the index terms used

to describe the articles. The second step was conducted
using controlled vocabulary and keywords from four data-
bases: PubMed, CINAHL, Web of Science and PsycINFO.
The search strategies for the PubMed, CINAHL, Web of
Science and PsycINFO databases are presented in online
supplemental appendix A. In the third step, the refer-
ence lists of identified reports and articles were searched
for additional sources. No additional references were
included in this study.
Screening and data abstraction
The titles and abstracts were imported into the Rayyan
QCRI online systematic review management programme17
and duplicates were removed. Rayyan is a free, online
application developed by QCRI to assist researchers
with systematic review methodology and meta-­ analysis
projects.18
The eligibility of the articles was determined based
on the inclusion and exclusion criteria described above.
Titles and abstracts were independently screened for
relevance by two reviewers (REFLdC, IA, NO, LS, APA
and JG). All studies that met the inclusion criteria were
considered. No instrument was used to assess the quality
of the studies. Disagreements between the reviewers were
resolved at a consensus meeting.
Full texts were evaluated for inclusion by two indepen-
dent reviewers (REFLdC, IA, NO and LS), and disagree-
ments were resolved by reaching consensus. Data from the
primary studies included in the review were extracted by
one reviewer (REFLdC, IA, NO and LS) using an abstrac-
tion tool developed by the study team. The following
data were collected: authors, title, study design, year of
publication, country of study, instrument(s) used to assess
the culture/safety climate and safety culture domains
evaluated.
Data analysis
A data analysis was performed to assess the constructs that
were most frequently mentioned in safety culture assess-
ments (online supplemental appendix B).
The data were organised by frequency and analysed
using RStudio Software. R is a free programming language
that offers various packages related to data quality assess-
ment for observational health studies.19 The analysis of
the domains identified in the surveys was performed
using the R interface for multidimensional analysis of
texts and questionnaires (IRaMuTeQ) V.0.7 alpha 2.20
This software can be a useful tool for processing data
from qualitative health research.21
Initially, in the analysis of the constructs, a figure used
as a basis on graph theory (similitude analysis) and a word
cloud were formed, through which it is possible to iden-
tify the textual occurrences between the words, helping to
identify the structure of the content of a textual corpus.
Three textual analyses were performed: (1) similitude
analysis, which makes it possible to identify the occur-
rences between the words and its result indicates the
connection between the words; (2) word cloud, in order to
Carvalho REFL, et al. BMJ Open Quality 2023;12:e002310. doi:10.1136/bmjoq-2023-002310
Open access
BMJ Open Qual: first published as 10.1136/bmjoq-2023-002310 on 10 October 2023. Downloaded from http://bmjopenquality.bmj.com/ on October 10, 2023 at UFC - Universidade Federal
group the words and organise them graphically according
to their relevance, the largest being those with the highest
frequency, considering words with a frequency equal to
or greater than 10 and (3) descending hierarchical clas-
sification to develop a dendrogram showing the classes
that emerged, and the higher the χ², the more the word
is associated with the class, and words with a frequency
equal to or greater than the value of the word were not
included.
The qualitative synthesis of the study results was
presented in tabular form describing factors identified
through this review related to safety culture and climate,
based on the identified culture and domain assessment
instruments.
RESULTS
Study characteristics
At the end of the search for the primary studies, 1864
records were identified in the selected databases
(figure 1). After eliminating duplicates (n=446), 1418
references remained (online supplemental appendix C).
The titles and abstracts of these publications were read,
and 605 studies were selected for full-­ text review. Of
do Ceara. Protected by copyright.
these, 357 were excluded because they did not meet the
eligibility criteria, and the sample comprised 248 primary
studies (figure 1) (online supplemental appendix D).
In the 248 primary studies included in the review, it
was found that research about the culture of safety was
conducted on all continents and in 64 different countries,
with the USA leading the evaluations (n=78), followed by
Brazil (n=22), Saudi Arabia (n=12), China (n=11) and
Taiwan (n=10). Regarding the year of publication of
the articles, we found that there was a record of studies
published between 1997 and 2022.
The most instruments for assessing safety culture
were the HSOPSC (n=104), SAQ (n=63), Safety Climate
Survey and Safety Organising Scale (n=8) in their orig-
inal versions, which evaluate the entire health institution,
and the versions adapted to the operating room, outpa-
tient clinic and intensive care unit. The most used instru-
ments in association with culture assessment scales were
the Maslach Burnout Inventory/Bargen Burnout Indi-
cator22 23 (n=13) and Culture Assessment Scales based on
patient perception (n=9).24 25
Regarding the study type, most studies evaluated safety
culture using a cross-­sectional design (n=233; 94%), nine
used intervention studies and five used cohort studies.
There were also eight mixed-­methods studies and four
qualitative studies that used interview techniques, open-­
ended questions, focus groups and brainstorming to
assess safety culture.
The number of domains evaluated by the instruments
varied from 5 to 12, and the number of items ranged from
9 to 46.
An additional 18 safety culture assessment tools have
been developed since 2008. These instruments address
factors that influence safety culture aimed at workers,
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BMJ Open Qual: first published as 10.1136/bmjoq-2023-002310 on 10 October 2023. Downloaded from http://bmjopenquality.bmj.com/ on October 10, 2023 at UFC - Universidade Federal
Figure 1 PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-­Analyses. do Ceara. Protected by copyright.

organisations, patients and families. Domains such as
teamwork, communication and management support
continue to be important factors for assessing safety
culture; however, there is a trend of instruments aimed
at assessing patient and family engagement, psychological
safety of the health team and engagement of nurses in
decision-­making. Table 1 lists the surveys as well as the
respective domains, number of items and levels of appli-
cation of the instrument.
Online supplemental table 1
For the analysis of the constructs, cultural assessment
surveys were conducted using only the most frequently
mentioned instruments described in online supplemental
table 1. Of the 248 articles, 66 included in their texts the
assessment of safety culture based on other constructs, in
addition to the domains of the most cited instruments.
Word cloud
A similarity analysis (figure 2A) was conducted and it was
observed that there are two prominent words, ‘commu-
nication’ and ‘leadership,’ with which all other words
are connected, and it should be noted that the words
‘satisfaction,’ ‘engagement,’ ‘nurse,’ ‘psychological,’
‘stress’ and ‘autonomy’ are connected to the word ‘lead-
ership’. The word ‘communication’ connects ‘teamwork,’

4 Carvalho REFL, et al. BMJ Open Quality 2023;12:e002310. doi:10.1136/bmjoq-2023-002310


Table 1 Factors identified in the review that make up the safety culture
Factors
 Organisational factors Open communication between patients
and families and healthcare teams
Open communication among
professionals
Leadership
Teamwork
Error notification and learning
Innovative climate
 Nurse engagement
 Factors related to professionals Well-­being
 Patient and family participation Patient and family participation
Carvalho REFL, et al. BMJ Open Quality 2023;12:e002310. doi:10.1136/bmjoq-2023-002310
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Definition
Refers to the extent to which patients
and families perceive that providers and
healthcare teams shared information and
invited discussion.62
Communication openness has been treated
as synonymous with listening, honesty,
frankness, trust, supportiveness, personal
opinions, suggestions and new ideas.63
The process through which an individual
attempts to intentionally influence another
individual or a group to accomplish a
goal.64
A dynamic process involving two or more
health professionals with complementary
backgrounds and skills, sharing common
health goals and exercising concerted
physical and mental effort in assessing,
planning or evaluating patient care. This
is accomplished through interdependent
collaboration, open communication
and shared decision-­making. This in
turn generates value-­added patient,
do Ceara. Protected by copyright.
organisational and staff outcomes.65
Report and learn from potentially harmful
errors that were intercepted before harm
was caused and errors that harmed
patients.66
Innovation climate could be defined
as the shared employee perceptions
that encourage employees to develop
innovative behaviours.67
Revealed the participatory role and
valued status of nurses in a broad
hospital context. Nurses were involved in
hospital and nursing department affairs
(internal governance, policy decisions
and committees), had opportunities for
advancement, communicate openly with
a responsive nursing administration and
acknowledged a powerful, visible and
accessible nurse executive.68
Job satisfaction and burnout were used as
indicators of work-­related well-­being.42Job
satisfaction is defined by employees’
connection to the organisation’s mission
and whether it is considered a good
place to work. Burn-­out is a syndrome
conceptualised as resulting from chronic
workplace stress that has not been
successfully managed.
This includes the patient and family’s
involvement in decision-­making on
boards or advisory committees at all
levels of healthcare, and involvement in
decision-­making about their own care and
treatment.69
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Figure 2 Similitude analysis.
‘empowerment,’ ‘learn’ and ‘management,’ ‘feedback,’
‘punitive’ and ‘trust’.
The word cloud allowed confirmation of the most
frequently cited words: ‘communication’ (f=23), ‘lead-
ership’ (f=24), ‘nurse’ (f=19), ‘management’ (f=16),
‘teamwork’ (f=13) and ‘job satisfaction’ (f=12). It should
be noted that the words ‘learn’ (f=8), ‘report’ (f=9),
‘empowerment’ (f=6) and ‘conflict’ (f=6) appeared with
little expressiveness; however, there was an increase in the
number of studies that associated safety culture with these
constructs (figure 2B).
Descending hierarchical classification
The general corpus consisted of 66 texts separated by 67
text segments (TS), using 45 text segments (67.16%).
There were 1159 occurrences, 430 distinct words and 261
words with a single occurrence. The analysed content was
categorised into two main classes, one of which was subdi-
vided into four classes. Class 1a: job satisfaction and lead-
ership (15.56%), class 1b: error response (22.22%), class
1c: psychological and empowerment nurses (20.00%),
class 1d: trust culture (22.22%) and class 2: innovation
worker (20.00%) (figure 3).
Class 1a: Job satisfaction and leadership comprised
15.56% (f=9 TS) of the total corpus analysed. Consisting
of words and radicals in the interval between χ²=3.41
(communication) and χ²=22.5 (satisfaction). This class also
includes words such as ‘leadership’ (χ²=10.23), ‘quality’
(χ²=8.46) and ‘engagement’ (χ²=6.39). Class 1b: Error
response comprised 22.22% (f=10 TS) of the total corpus
analysed and included words and radicals in the interval
between χ²=3.09 (learn) and χ²=34.17 (error). This class
is also composed of words such as ‘response’ (χ²=19.69);
‘punitive’ (χ²=15.37); ‘feedback’ (χ²=14.96), ‘communi-
cation’ (χ²=13.39) and ‘openness’ (χ²=10.86), ‘teamwork’
(χ²=5.85). Class 1c: Psychological and empowerment
6 Carvalho REFL, et al. BMJ Open Quality 2023;12:e002310. doi:10.1136/bmjoq-2023-002310
BMJ Open Qual: first published as 10.1136/bmjoq-2023-002310 on 10 October 2023. Downloaded from http://bmjopenquality.bmj.com/ on October 10, 2023 at UFC - Universidade Federal
nurses and physician comprised 20.00% (f=9 TS) of the
total corpus analysed and consisted of words and radicals
do Ceara. Protected by copyright.
in the interval between χ²=2.47 (conflict) and χ²=17.56
(psychological). This class was composed of words such
as ‘empowerment’ (χ²=12.66); ‘nurse’ (χ²=9.42); ‘physi-
cian’ (χ²=9.42), ‘support’ (χ²=4.75) and ‘interpersonal’
(χ²=4.37). Class 1d: Trust culture comprises 22.22%
(f=10 TS) of the total corpus analysed and included
words and radicals in the interval χ²=5.85 (report) and
χ²=15.37 (trust). In addition to these two words, this
class is composed of the word ‘culture’ (χ²=7.95). Class
2: Innovation worker comprises 20.00% (f=9 TS) of the
total corpus analysed and consisted of words and radicals
in the interval between χ²=17.56 (4 words) and χ²=22.50
(innovation). This class was composed of words such as
‘worker’ (χ²=17.56), ‘equipment’ (χ²=17.56), ‘availability’
(χ²=17.56) and ‘control’ (χ²=17.56).
Based on the results of this review, we constructed a
summary of the domains that make up safety culture,
based on the factors related to organisations in general,
health professionals, and patient and family participation
(table 1).
DISCUSSION
We investigated, evaluated and synthesised the safety
culture factors addressed in assessment instruments in
the literature. We found an increasing number of articles
published starting in 1999 were observed, a year that was
considered a milestone for patient safety due to the To
Err and Human report by the American Institute of Medi-
cine.26 This report, in addition to drawing attention to the
number of errors that occurred due to avoidable events,
showed the multicausality of these events, presenting
the environmental and individual factors that could be
involved in the error. Several studies began to appear to

Figure 3 Descending hierarchical classification analysis.
assess the organisational and individual factors that could
lead to such events.
Since March 1999, it has been observed that the USA
remains at the forefront of research on the development
and evaluation of the culture of safety (n=129). However,
many other countries have reported and published results
on the assessment of the safety culture of their institu-
tions, including Brazil,27–29 Saudi Arabia,30–32 China33–35
and Taiwan.36 37 Although the assessment of the culture
of a particular location, region or country is an area of
interest to local managers and professionals, it has been
observed that these publications have helped refine the
instruments for this purpose.38 39 It allows for the compar-
ison of perceptions among health professionals,40 in
addition to allowing systematic literature reviews on the
subject.11
The HSOPSC was the most used instrument worldwide
to assess safety culture, followed by the SAQ and the SCS,
similar results were reported in the literature.11 41 These
instruments have 5–12 domains focused on the organisa-
tional assessment of patient safety and evaluate domains
related to teamwork environment, management, commu-
nication, working conditions, error reporting and job
satisfaction, except for the SCORE,42 43 which evaluates
burnout climate and personal burnout. This is the only
instrument that considers, in addition to organisational
factors, factors related to professionals.
Evaluating safety culture is a complex process, and
researchers have drawn attention to the fact that the
Carvalho REFL, et al. BMJ Open Quality 2023;12:e002310. doi:10.1136/bmjoq-2023-002310
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do Ceara. Protected by copyright.
available instruments have evaluated tangible concepts of
safety culture and suggested an approach that combines
different methodologies to assess intangible factors, that
is, factors that are not easily evaluated by questionnaires,
but which are just as important as measurable constructs.
For the authors, intangible factors are trust, commitment,
psychological safety, guilt and shame.12
Regarding the methodological approach, although
most studies used a cross-­ sectional design, 12 studies
used a mixed- methods or qualitative approach, showing
that researchers have been evaluating the constructs that
permeate safety culture in greater depth. The techniques
used for qualitative analysis included interviews, focus
groups and brainstorming. To correlate safety culture
with other concepts, research has been associated with
burnout,44–46 patient perception of their safety47 and
teamwork.48
Such research shows that more than a decade ago,
factors related to the well-­being of health workers and
the participation of patients and families may have
directly resulted in the institutional safety climate. In
2022, the WHO included as one of the strategic objec-
tives to strengthen patient safety in health institutions,
the engagement of patients and families at all levels of
healthcare, ranging from policy development and plan-
ning to the supervision of performance, to fully informed
consent and shared decision-­making in healthcare.1
These results can be confirmed by the number of instru-
ments developed since 2008 that assess factors related to
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the safety culture aimed at health workers, organisations
and the patient and family. In addition to the most eval-
uated domains, these instruments assess factors related
to patient and family engagement, the psychological
safety of the health team, and nurses’ engagement in
decision-­ making. Lower levels of psychological safety
and organisational support were significant predictors
for remaining silent about safety concerns.49 There are
positive relationships between quality and a climate of
safety, empowerment and satisfaction with the provision
of care with the culture of safety and empowerment of the
family.50 In addition to the fact that there is already a body
of evidence that the involvement of nurses in decision-­
making is beneficial for patient safety51 52 it can also be
said that the involvement of this profession can reduce
the costs of health institutions.53
Regarding the analysis of the data of the identified
constructs, it was observed that two words (‘communi-
cation’ and ‘leadership’) were more prominent about
connectivity with other words. The dendrogram confirms
the findings in the word cloud and similarity analysis of
the constructs extracted from the articles. According
to the research articles, the constructs that form safety
culture can be divided into two main classes, one of which
is subdivided into five: class 1a ‘job satisfaction and lead-
ership,’ class 1b ‘error response,’ class 1c ‘psychological
and empowerment nurse,’ class 1d ‘trust culture’ and
class 2 ‘innovation worker’.
Classes 1a–d consist of constructs that have already
been researched and have scientific evidence showing
their association with a positive safety culture. Institutions
with strengthened and inclusive leadership favour the
autonomy of professionals, improve nurses’ engagement
and consequently increase their satisfaction and the well-­
being of professionals. A study conducted with 451 nurses
from 5 hospitals in Wuhan, China, showed that nurses
who were on the front line of COVID-­19 care presented
severe psychological distress; however, nurses who had
more inclusive managers showed less psychological
distress. Inclusive leaders involved the team in decision-­
making and created work environments that were consid-
ered psychologically safe.54 Leadership is identified as a
strong influencing factor for a culture of trust in which
professionals can speak openly about mistakes without
guilt or fear, because in trustworthy environments, in
addition to talking about mistakes, there is certainty of
collective learning.55
However, research highlights that it is critical to pay
attention to the need to train first-­line nursing leaders to
establish advice in a shared governance structure that can
significantly contribute to the realisation of an improved
safety culture. Nursing leadership style is perhaps the most
critical factor in determining the culture and climate that
will be created in a unit and within an organisation.56 57
The nursing leadership style can promote professional
autonomy by enhancing decision-­making, allowing nurses
to make timely and accurate judgments based on their
knowledge, which leads to greater patient safety. It also
8 Carvalho REFL, et al. BMJ Open Quality 2023;12:e002310. doi:10.1136/bmjoq-2023-002310
BMJ Open Qual: first published as 10.1136/bmjoq-2023-002310 on 10 October 2023. Downloaded from http://bmjopenquality.bmj.com/ on October 10, 2023 at UFC - Universidade Federal
encourages critical thinking, allowing the independent
analysis of patient conditions, identification of risks and
immediate action. It promotes a culture of accountability
and commitment to patient safety as professionals take
responsibility for their practices and outcomes. Finally,
it fosters improved communication and collaboration
among healthcare teams by facilitating the expression of
concerns, ideas and suggestions, leading to better coor-
dination, sharing of vital information, and, ultimately,
safety patient care.
Although leadership is the basis for strengthening all
other constructs of safety culture, it was observed that
open communication is a cross-­ cutting factor in this
process and favours the empowerment of professionals,
teamwork and the construction of a reliable environ-
ment to talk about errors and learn from them. There are
strong associations between satisfactory communication
and aspects of the patient’s safety climate, such as team-
work and job satisfaction.58
Finally, the class 2 ‘innovation worker,’ which in the
literature can also be found to be associated with innova-
tive behaviours and innovation climate, is a novel result
among the findings of the present review, since it is a
construct that has been addressed in studies on safety
do Ceara. Protected by copyright.
culture, but emerged in this study as a preeminent class,
highlighting its importance as a component factor. An
innovative climate can be defined as shared employee
perceptions that encourage employees to develop inno-
vative behaviours. Institutions with a good safety climate
support employees and create a positive attitude towards
innovation.59 60 Organisational climate has a significant
impact on innovative behaviour and suggests that nursing
managers should foster innovation through improve-
ments in the organisational climate.37 Initially, the inno-
vation construct was included as one of the climate
assessment constructs in the team climate inventory
(TCI).61 According to the authors, four theoretical factors
support TCI: vision, participatory safety, task orientation
and support for innovation. Although the instrument is
considered valid and reliable, further studies are required
to strengthen its psychometric properties.61
A limitation of this review is the analysis of articles
in English only, which may have excluded important
research in other languages.
CONCLUSION
The identified instruments presented elements that
remain indispensable for assessing safety culture, such
as leadership commitment, open communication and
learning from mistakes. However, there is a trend in
research aimed at evaluating patient and family engage-
ment, psychological safety, nurses’ engagement in
decision-­
making and innovation. The concepts iden-
tified in the safety culture assessment can be divided
into organisational, professional, and patient and family
participation. However, these three dimensions were
not identified by using the same instrument. Thus, this

review may serve to construct and update safety culture
instruments addressing constructs aligned with research
in the area and with the principles of the WHO GPAPS
2021–2030.
Although tools such as questionnaires are generally
easy to administer, the true improvement in safety culture
lies in the effective implementation and action of the
results obtained. By examining change management
processes and the ease of implementing interventions
based on questionnaire findings, researchers can gain
insights into how organisations translate survey results
into meaningful actions that enhance the safety culture.
This broader perspective would provide a more compre-
hensive understanding of the impact of questionnaires
on safety culture improvements.
Exploring topics such as leadership support, employee
engagement, organisational readiness and the effective-
ness of interventions derived from the questionnaire
results can contribute to the development of best prac-
tices and strategies for leveraging survey data to drive
positive change and improve safety culture in healthcare
settings.
Expanding research in this direction would enable
a deeper exploration of the practical applications and
outcomes of questionnaire-­based assessments, ultimately
providing valuable insights for organisations seeking to
foster a safety culture.
Contributors Conceptualisation, REFLdC; data curation: REFLdC, IA, NO and LS;
formal analysis, REFLdC, DWB, AS and IA; methodology: APA, REFLdC, LS, JG and
MG; project administration: REFLdC; visualisation: REFLdC; writing—original draft
preparation: REFLdC, DWB and AS; writing—review and editing: REFLdC, IA, APA,
LS, JG, MG, NO and DWB. All authors have read and agreed to the published version
of the manuscript. The guarantor was REFLdC.
Funding This research was funded by the CNPQ in the form of a post-­doctoral
scholarship, process number 203394/2020-­8.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request.
Supplemental material This content has been supplied by the author(s). It
has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have
been peer-­reviewed. Any opinions or recommendations discussed are solely
those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability
and responsibility arising from any reliance placed on the content. Where the
content includes any translated material, BMJ does not warrant the accuracy and
reliability of the translations (including but not limited to local regulations, clinical
guidelines, terminology, drug names and drug dosages), and is not responsible
for any error and/or omissions arising from translation and adaptation or
otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iD
Rhanna Emanuela Fontenele Lima de Carvalho http://orcid.org/0000-0002-3406-​
9685
Carvalho REFL, et al. BMJ Open Quality 2023;12:e002310. doi:10.1136/bmjoq-2023-002310
Open access
BMJ Open Qual: first published as 10.1136/bmjoq-2023-002310 on 10 October 2023. Downloaded from http://bmjopenquality.bmj.com/ on October 10, 2023 at UFC - Universidade Federal
REFERENCES
1 World Health Organization. Global patient safety action plan 2021–
2030: towards eliminating Avoidable harm in health care. Geneva,
2021.
2 Merino-­Plaza MJ, Carrera-­Hueso FJ, Roca-­Castelló MR, et al.
Relationship between job satisfaction and patient safety culture. Gac
Sanit 2018;32:352–61.
3 Lockwood AM, Proulx J, Hill M, et al. Using safety culture results to
guide the merger of four general practices in the UK. BMJ Open Qual
2020;9:e000860.
4 Sexton JB, Helmreich RL, Neilands TB, et al. The safety attitudes
questionnaire: psychometric properties, benchmarking data, and
emerging research. BMC Health Serv Res 2006;6:44.
5 R. M. Agency for Healthcare Research and Quality, “What Is patient
Safety Culture?", March . 2022Available: https://www.ahrq.gov/sops/​
about/patient-safety-culture.html
6 Vierendeels G, Reniers G, van Nunen K, et al. An integrative
conceptual framework for safety culture: the egg aggregated model
(TEAM) of safety culture. Safety Science 2018;103:323–39.
7 Churruca K, Ellis LA, Long JC, et al. An exploratory survey study of
disorder and its association with safety culture in four hospitals. BMC
Health Serv Res 2022;22:530.
8 Zohar D. Thirty years of safety climate research: reflections and
future directions. Accid Anal Prev 2010;42:1517–22.
9 Guldenmund FW. The nature of safety culture: a review of theory and
research. Safety Science 2000;34:215–57.
10 Cooper Ph.D. MD. Towards a model of safety culture. Safety Science
2000;36:111–36.
11 Churruca K, Ellis LA, Pomare C, et al. Dimensions of safety culture: a
systematic review of quantitative, qualitative and mixed methods for
assessing safety culture in hospitals. BMJ Open 2021;11:e043982.
12 Malik RF, Buljac-­Samardžić M, Akdemir N, et al. What do we really
assess with organisational culture tools in healthcare? an interpretive
do Ceara. Protected by copyright.
systematic umbrella review of tools in Healthcare. BMJ Open Qual
2020;9:e000826.
13 Aromataris E, Munn Z, eds. In: JBI Manual for Evidence Synthesis.
2020.
14 Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for Scoping
reviews (PRISMA-­SCR): checklist and explanation. Ann Intern Med
2018;169:467–73.
15 Munn Z, Pollock D, Khalil H, et al. What are Scoping reviews?
providing a formal definition of scoping reviews as a type of evidence
synthesis. JBI Evid Synth 2022;20:950–2.
16 Foster ED, Deardorff A. Open science framework (OSF. Jmla
2017;105.
17 Ouzzani M, Hammady H, Fedorowicz Z, et al. Rayyan—a web and
mobile app for systematic reviews. Syst Rev 2016;5:210.
18 Johnson N, Phillips M. Rayyan for systematic reviews. Journal of
Electronic Resources Librarianship 2018;30:46–8.
19 Mariño J, Kasbohm E, Struckmann S, et al. R packages for data
quality assessments and data monitoring: a software scoping review
with recommendations for future developments. Applied Sciences
2022;12:4238.
20 Camargo BV, Justo AM. IRAMUTEQ: um software Gratuito para
Análise de Dados Textuais. Temas Psicol 2013;21:513–8.
21 Souza MAR de, Wall ML, Thuler AC de MC, et al. O USO do software
IRAMUTEQ NA Análise de Dados em Pesquisas Qualitativas. Rev
Esc Enferm USP 2018;52:0.
22 Feldt T, Rantanen J, Hyvönen K, et al. The 9-­item Bergen burnout
inventory: factorial validity across organizations and measurements
of longitudinal data. Ind Health 2014;52:102–12.
23 Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol
2001;52:397–422.
24 Hartmann CW, Meterko M, Zhao SB, et al. Validation of a novel
safety climate instrument in VHA nursing homes. Med CARE Res Rev
2013;70:400–17.
25 Wagner A, Michaelis M, Luntz E, et al. Assessment of patient
and occupational safety culture in hospitals: development of a
questionnaire with comparable dimensions and results of a feasibility
study in a German University hospital. Int J Environ Res Public Health
2018;15:2625.
26 C. J. D. M. Kohn LT. To err is human: building a safer health system;
2000.
27 Carvalho REFL de, Arruda LP, Nascimento NKP do, et al.
Assessment of the culture of safety in public hospitals in Brazil. Rev
Lat Am Enfermagem 2017;25:e2849.
28 de Lima Silva Nunes R, de Camargo Silva AEB, de Lima JC, et al.
Factors influencing the patient safety climate in intensive care units:
cross-­sectional study. BMC Nurs 2021;20:1.
29 Prates CG, Caregnato RCA, Magalhães AMM de, et al.
Evaluation of patient safety culture in a private general
9
Open access
hospital: a case study in Brazil. Int J Health Care Qual Assur
2021;ahead-­of-­print(ahead-­of-­print):110–21.
30 Alquwez N, Cruz JP, Almoghairi AM, et al. Nurses’ perceptions
of patient safety culture in three hospitals in Saudi Arabia. J Nurs
Scholarsh 2018;50:422–31.
31 Alsabaani AA. Perceptions of patient safety culture among
physicians and nurses in a tertiary hospital in southwestern Saudi
Arabia. WORLD FAMILY MEDICINE 2020;18:5–12.
32 Colet PC, Cruz JP, Cacho G, et al. Perceived infection prevention
climate and its predictors among nurses in Saudi Arabia. J Nurs
Scholarsh 2018;50:134–42.
33 Jiang K, Tian L, Yan C, et al. A cross-­sectional survey on patient
safety culture in secondary hospitals of northeast China. PLoS ONE
2019;14:e0213055.
34 Zhong X, Song Y, Dennis C, et al. Patient safety culture in Peking
University cancer hospital in China: baseline assessment and
comparative analysis for quality improvement. BMC Health Serv Res
2019;19:1.
35 Zhou P, Li MQ, Wei XF, et al. Patient safety climate in general public
hospitals in China: a Multiregion study. J Patient Saf 2021;17:522–30.
36 Wagner C, Smits M, Sorra J, et al. Assessing patient safety
culture in hospitals across countries. Int J Qual HEALTH CARE
2013;25:213–21.
37 Weng R-­H, Huang C-­Y, Chen L-­M, et al. Exploring the impact of
Transformational leadership on nurse innovation behaviour: a cross-­
sectional study. J Nurs Manag 2015;23:427–39.
38 Calvache JA, Benavides E, Echeverry S, et al. Psychometric
properties of the Latin American Spanish version of the hospital
survey on patient safety culture questionnaire in the surgical setting.
J Patient Saf 2021;17:e1806–13.
39 Zebrak K, Yount N, Sorra J, et al. Development, pilot study, and
Psychometric analysis of the AHRQ surveys on patient safety
culture™ (SOPS®) workplace safety supplemental items for hospitals
. Int J Environ Res Public Health 2022;19:6815.
40 Fassarella CS, Camerini FG, Henrique D de M, et al. Evaluation of
patient safety culture: comparative study in university hospitals. Rev
Esc Enferm USP 2018;52.
41 Colla JB, Bracken AC, Kinney LM, et al. Measuring patient safety
climate: a review of surveys. Qual Saf Health Care 2005;14:364–6.
42 Sexton JB, Adair KC, Profit J, et al. Safety culture and workforce
well-­being associations with positive leadership Walkrounds. Jt
Comm J Qual Patient Saf 2021;47:403–11.
43 Adair KC, Quow K, Frankel A, et al. The improvement readiness
scale of the SCORE survey: a metric to assess capacity for quality
improvement in Healthcare. BMC Health Serv Res 2018;18:975.
44 de Lima Garcia C, Bezerra IMP, Ramos JLS, et al. Association
between culture of patient safety and burnout in pediatric hospitals.
PLoS One 2019;14:e0218756.
45 Eltaybani S, Yamamoto-­Mitani N, Ninomiya A, et al. The association
between nurses' burnout and objective care quality indicators:
a cross-­sectional survey in long-­term care wards. BMC Nurs
2021;20:34.
46 Swamy L, Mohr D, Blok A, et al. Impact of workplace climate
on burnout among critical care nurses in the veterans health
administration. Am J Crit CARE 2020;29:380–9.
47 Madden C, Lydon S, Murphy AW, et al. Development and validation
of a patient-­report measure of safety climate for general practice.
Family Practice 2021.
48 Schwartz ME, Welsh DE, Paull DE, et al. The effects of crew resource
management on teamwork and safety climate at veterans health
administration facilities. J Healthc Risk Manag 2018;38:17–37.
10 Carvalho REFL, et al. BMJ Open Quality 2023;12:e002310. doi:10.1136/bmjoq-2023-002310
BMJ Open Qual: first published as 10.1136/bmjoq-2023-002310 on 10 October 2023. Downloaded from http://bmjopenquality.bmj.com/ on October 10, 2023 at UFC - Universidade Federal
49 Schwappach DLB, Gehring K. Frequency of and predictors for
withholding patient safety concerns among oncology staff: a survey
study. Eur J Cancer Care (Engl) 2015;24:395–403.
50 Burlakov N, Rozani V, Bluvstein I, et al. The association between
quality and safety climate of a hospital ward, family members’
empowerment, and satisfaction with provided care. J Nurs Scholarsh
2021;53:727–36.
51 Brooks Carthon JM, Hatfield L, Plover C, et al. Association of nurse
engagement and nurse staffing on patient safety. J Nurs Care Qual
2019;34:40–6.
52 Dempsey C, Assi MJ. The impact of nurse engagement on quality,
safety, and the experience of care. Nurs Adm Q 2018;42:278–83.
53 Kutney-­Lee A, Germack H, Hatfield L, et al. Nurse engagement
in shared governance and patient and nurse outcomes. JONA
2016;46:605–12.
54 Zhao F, Ahmed F, Faraz NA. Caring for the Caregiver during
COVID-­19 outbreak: does inclusive leadership improve psychological
safety and curb psychological distress? A cross-­sectional study. Int J
Nurs Stud 2020;110:103725.
55 Farnese ML, Zaghini F, Caruso R, et al. Managing care errors in the
wards. LODJ 2019;40:17–30.
56 Battard J. Nonpunitive response to errors fosters a just culture. Nurs
Manage 2017;48:53–5.
57 Gottlieb LN, Gottlieb B, Bitzas V. Creating empowering
conditions for nurses with workplace autonomy and agency:
how Healthcare leaders could be guided by strengths-­based
nursing and Healthcare leadership (SBNH-­L. J Healthc Leadersh
2021;13:169–81.
58 Yoo J, Chung SE, Oh J. Safety climate and organizational
communication satisfaction among Korean perianesthesia care unit
nurses. J Perianesth Nurs 2021;36:24–9.
59 Dackert I. The impact of team climate for innovation on well-­being
and stress in elderly care. J Nurs Manag 2010;18:302–10.
60 Sarros JC, Cooper BK, Santora JC. Building a climate for
do Ceara. Protected by copyright.
innovation through transformational leadership and organizational
culture. Journal of Leadership & Organizational Studies
2008;15:145–58.
61 Anderson NR, West MA. Measuring climate for work group
innovation: development and validation of the team climate inventory.
J Organiz Behav 1998;19:235–58.
62 Prentice JC, Bell SK, Thomas EJ, et al. Association of open
communication and the emotional and behavioural impact of medical
error on patients and families: state-­wide cross-­sectional survey.
BMJ Qual Saf 2020;29:883–94.
63 Rogers DP. The development of a measure of perceived
communication openness. Journal of Business Communication
1987;24:53–61.
64 Fischer SA, Jones J, Verran JA. Consensus achievement of
leadership, organisational and individual factors that influence
safety climate: implications for nursing management. J Nurs Manag
2018;26:50–8.
65 Xyrichis A, Ream E. Teamwork: a concept analysis. J Adv Nurs
2008;61:232–41.
66 To err is human. Washington,DC: National Academies Press, 2000
67 Newman A, Round H, Wang S, et al. Innovation climate: a systematic
review of the literature and agenda for future research. J Occupat &
Organ Psyc 2020;93:73–109.
68 Lake ET. Development of the practice environment scale of the
nursing work index. Res Nurs Health 2002;25:176–88.
69 World Health Organization. Patients for patient safety: partnerships
for safer health care. Geneva, 2013.