International Journal of Africa Nursing Sciences 14 (2021) 100287

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Patient safety attitude and associated factors among nurses at Mansoura

University Hospital: A cross sectional study
Shahenda A. Salih a, b, *, Fadia A. Abdelkader Reshia a, c, Wafa Abdein Humza Bashir d, e,
Ayat M. Omar a, f, Shereen Ahmed Elwasefy a, c
a
College of Applied Medical Sciences, Jouf University, Saudi Arabia
b
Faculty of Medical Technical Science, Alzaiem Alazhari University, Sudan
c
Faculty of Nursing, Mansoura University, Egypt
d
Faculty of Nursing Sciences, Jazan University, Saudi Arabia
e
Faculty of Nursing Science, Khartoum University, Sudan
f
Faculty of Nursing, Fayoum University, Egypt

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Patient safety is a high priority for the healthcare system worldwide. It is considered an indicator of
Patient safety the quality of care.
Attitude Objective: This research assesses Egyptian nurses’ attitude to patient safety and the factors that affect their
Nurses
attitude.
Associated factors
Patient safety attitude questioner
Methods: A descriptive cross-sectional study. Data were collected using the staff information form and safety
attitudes questionnaire. The study population was 350 nurses working in Mansoura University Hospital. Data
were analyzed with frequency, percentage, mean, standard deviation, the Chi squire test, and ANOVA tests using
SPSS.
Results: None of the six domains of safety attitude – job satisfaction, teamwork, safety climate, the perception of
management, stress recognition, and working conditions – were awarded a positive mean score above 75. 51.4%
of the nurses had a neutral attitude toward patient safety. The main associated factors were educational level,
experience, and attending training courses related to patient safety, which had a high effect on nurses’ attitude
(p-value < 0.01); age and marital status had a slight effect (p-value < 0.05), while gender and working unit had
no significant relationship (p-value > 0.05).
Conclusions: The attitude of nurses towards patient safety at Mansoura University Hospital was neutral, and
strongly associated with educational level, years of experience, and attending training courses on patient safety.
Therefore, it is strongly recommended to develop strategies towards an increasingly successful patient safety
culture.

1. Introduction
Provision of care in clinical settings is associated with a variety of
concerns including adverse effects of treatment, accidents, and medical
errors. Failure to maintain patients’ safety entails a significant increase
in the cost of care, morbidity and mortality. Patient safety is a priority in
the healthcare system not only to improve the outcome of treatment but
also to prevent complications (Al-Ahmadi, 2009; Zhao et al., 2019).
Patient safety involves measures to eliminate accidents and adverse
effects in clinical settings (Asem, Sabry, & Elfar, 2019). Every year many
patients suffer from disabilities, injuries, or mortality as a result of
unsafe medical treatment. One study reported that 2.6 million patients
lose their life annually as a consequence of lack of compliance with
safety standards. This in turn affects the personal, social, and economic
aspects of their families’ lives and makes the loss even worse (Organi­
zation, 2019).
Patient safety is a multi-level framework including a variety of fac­
tors such as teamwork, climate protection, employee satisfaction,
working environment, stress awareness, management perception, and
attitude (Aboul-Fotouh, Ismail, Ez Elarab, & Wassif, 2012; Carthon
et al., 2019). Acknowledging these safety factors is the cornerstone in
improving the safety performance of healthcare providers (Bahar &

* Corresponding author at: Nursing Department, College of Applied Medical Sciences, Jouf University, Sekaka, Saudi Arabia.
E-mail address: shahenda@ju.edu.sa (S.A. Salih).

https://doi.org/10.1016/j.ijans.2021.100287
Received 14 September 2020; Received in revised form 15 January 2021; Accepted 18 January 2021
Available online 2 February 2021
2214-1391/© 2021 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
S.A. Salih et al.
Önler, 2020; Zeynep et al., 2020).
The literature indicates that the incidence of medical errors and
adverse outcomes is strongly influenced by healthcare professionals’
attitude towards safety (Elmontsri, Almashrafi, Banarsee, & Majeed,
2017). Nurses play a critical role in protecting and supporting patients,
because of the nature of their job. They are the first-line care providers
and spend more time on patient care than any other healthcare profes­
sional (Balamurugan & Flower, 2015). Their patient safety assessment
serves as a reliable predictor of overall hospital safety. It is imperative
that nurses engage with other healthcare providers in the creation and
enhancement of the attitude towards patient safety (Kim & Jeong,
2019). A positive attitude toward patient safety is associated with a
significant reduction in complications (Pelzang & Hutchinson, 2018).
2. Significance of study
Studies report a notable increase in the rate of harmful events in
developing countries compared to the modern world. One study
revealed that low- to moderate-income countries have 134 million
harmful events annually, resulting in 2.6 million deaths every year
(Auraaen, Slawomirski, & Klazinga, 2018; Siddiqi et al., 2012). In Egypt,
one study reported an adverse event rate of 6% among in-patients.
Nearly a third of these events caused mortality, and 18% permanent
disabilities (Abdelhai, Abdelaziz, & Ghanem, 2012). In contrast, the rate
of harmful events/number of in-patients in the Western world ranges
from 8% to 18%. Few studies have investigated the attitude of Egyptian
nurses toward patient safety; one (N = 479) reported a poor safety
attitude score (El-Sherbiny, Ibrahim, & Abdel-Wahed, 2020).
Assessment of nurses’ attitude toward patient safety helps to reduce
harmful events in clinical settings, by acknowledging the factors that
affect their attitude. Findings from this study are therefore expected to
inform the decision makers and other stakeholders about the attitude of
nurses, helping them to revise and develop policies that influence
nurses’ safety attitude. They will also enrich the body of knowledge by
providing information about the factors that impact nurses’ attitude.
3. Aim of the study
To assess patient safety attitudes among nurses at the Mansoura
University Hospital, Egypt.
To investigate the factors that affect nurses’ attitudes to patient
safety.
4. Material and methods
4.1. Study design and setting
This study used a descriptive, cross-sectional design to answer these
research questions.
The study took place in Mansoura University Hospital, the biggest
referral and teaching hospital in eastern Egypt. It is a tertiary health
centre with more than 1000 beds. The selection of this hospital was
based on its high bed capacity, the large number of nurses (670), and
availability of ethical permission.
4.2. Sampling
A convenience sample of 350 nurses was used in this study. Nurses
were selected from six wards: triage, labour room, operating room,
emergency room, intensive care unit and in-patient. The calculation of
the sample size was based on the formula from Suresh and Chandra­
shekara (2012). Type I error was set at α = 0.5.
4.3. Inclusion criteria
Nurses of both genders who have more than one year of experience
2
International Journal of Africa Nursing Sciences 14 (2021) 100287
were considered eligible participants.
4.4. Data collection
Nurses were approached in their working units during the day shift.
A brief orientation about the study and instructions on how to complete
the questionnaire were provided by the principal investigator. Partici­
pants were informed that participation was voluntary and they could
withdraw at any time with no penalty. No identifying information was
requested, in order to maintain confidentiality. The privacy of partici­
pants was considered and they were directed to a private room to
complete the questionnaire. No reward was given, although the nurses
were informed that their participation would enhance their nursing
knowledge. The participants were informed that their completion of the
questionnaire was considered consent to participate.
4.5. Tool
Data were collected using two tools: a participants’ characteristics
form, and a patient safety attitude questionnaire. The characteristics
form was developed by the research team specifically for this study, and
comprised six items: age, gender, marital status, educational level, years
of experience, and attendance on training courses related to patient
safety. The patient safety attitude questionnaire, developed by Sexton
et al. (2006), has 46 items divided into six domains: job satisfaction (11
items), teamwork (12 items), safety climate (5 items), perception of
management (7 items), stress recognition (5 items), and working con­
ditions (6 items). The tool is available free online in multiple languages.
Responses were measured on a Likert scale where “strongly disagree”
was given deserved 0 points, “slightly disagree” 25, “slightly neutral”
deserved 50, “slightly agree” 75, and “strongly agree” 100 points. Po­
tential scores thus ranged from 0 to 100, with the highest score indi­
cating a positive and optimistic attitude. A score higher than 75 was
considered adequate. Some items were reverse coded and this was
considered during data analysis.
The patient safety attitude questionnaire is valid and reliable with
Cronbach’s alpha values reported at 0.72–0.93. The original version was
translated into Arabic, and a pilot study conducted at the hospital
further confirmed its validity and reliability. The content of the trans­
lated version was validated by a panel of five nursing lecturers; no
changes were required.
4.6. Data analysis
The Statistical Package for Social Sciences (SPSS version 26) (Ein­
stein & Abernethy, 2000) was used to analyze the data. Descriptive
statistics (frequency, percentage, mean and standard deviation) were
used to describe participants’ characteristics. The attitude scores were
summed to calculate the level of safety attitude. ANOVA and Chi-square
tests were used to assess differences between the groups. The level of
statistical significance was set at P = 0.05.
4.7. Ethical consideration
Ethical permission was granted from Mansoura University Hospital’s
Ethics Committee (number 09-09/41). The research team guaranteed
the confidentiality of the information. Data were stored on the principal
investigator’s personal computer with restricted access. All hardcopies
was discarded appropriately at the end of the study.
5. Results
Mean scores for job satisfaction, teamwork, and security climate
were 34.32 (SD = 9.01), 42.61 (SD = 6.90), and 17.49 (SD = 4.09),
respectively. Those for management perception, stress identification,
and working conditions were 23.98 (SD = 5.65), 14.62 (SD = 3.65), and
S.A. Salih et al. International Journal of Africa Nursing Sciences 14 (2021) 100287

18.24 (SD = 2.29), respectively. Finally, the mean score of total nurses’ Table 2
attitudes related to patient safety was 151.26 (SD = 29.8). See Table 2. Attitudes to patient safety (N = 350).
There was a statistically significant association between nurses’ Domains N. Items Mean SD Min Max
attitude to patient safety and age, and marital status (p-value < 0.05).
Job satisfaction 11 34.32 ± 9.01 11 55
There was also a statistically significant association between attitude Teamwork 12 42.61 ± 6.90 18 58
and educational level, experience, and previous patient safety training Safety Climate 5 17.49 ± 4.09 5 25
courses (p-value < 0.01). On the other hand, there was no significant Perception of management 7 23.98 ± 5.65 7 35
association with gender or working unit (p-value > 0.05). See Table 3. Stress recognition 5 14.62 ± 3.65 5 24
Working condition 6 18.24 ± 2.29 11 25
Table 4 shows that educational level, years of experience, and Total 46 151.26 ± 29.8 57 222
training courses had a high predictive effect on attitude to patient safety
(p-value < 0.01). However, age and marital status had only a slight ef­
fect on attitude (p-value < 0.05).
Table 3
Relationship between demographic data and total attitude to patient safety.
6. Discussion
Items Mean SD X2 P Value

This study aimed to assess nurses’ attitude to patient safety and the Age (year)
factors that affect their attitude. It found that their attitude was disap­ 18-30 159.41±26.4 F test
31-40 156.30±30.3
pointing. Educational level, years of experience, and previous training in
41-50 150.11±25.7 3.964 .014*
patient safety were associated with patient safety. In the current study, Above 50 148.02±31.4
the teamwork domain had the highest score, followed in order by job
Gender
satisfaction, perception of management, working conditions, and safety Male 151.73±27.6 T test
climate. The stress recognition domain had the lowest score. Female 150.97±25.5 1.871 0.051
The research found that nurses’ safety attitude was mostly neutral.
Marital status
This result is consistent with findings from Bahar and Önler (2020), who Single 158.34±31.2 F test
Widow 146.17±27.1
Divorced 150.08±24.4 4.001 .010*
Table 1 Married 149.31±26.0
Demographic characteristics of subjects (N = 350). Educational level
Items N % Nursing Diploma 148.3±27.16 F test
Bachelor’s Degree 155.7±20.3
Age (year) Master’s Degree 158.64±24.1 6.994 .004**
18-30 268 76.6 PhD 161.01±23.1
31-40 66 18.9
41-50 14 4 Working units
Above 50 2 0.6 Triage 149.2±18.7 F test
Mean (SD) Labor room 142.0±20.6
27.12 (5.37) Emergency Room 150.1±23.1 1.041 0.062
Intensive Care Unit 147.8±22.5
Gender Operating Room 152.5±25.1
Male 88 25.1 Inpatients wards 154.7±24.1
Female 262 74.9
Years of Experience
Marital status 1-5 years 157.61±27.4 F test
Single 164 46.9 6-10 years 155.01±31.4 .008**
Widow 2 0.6 11-15 years 149.2 ±26.0 5.976
Divorced 4 1.1 More than 15 years 147.04±28.5
Married 180 51.4
Training courses related to patient safety
Educational level Yes 157.84 T test
Nursing Diploma 42 12 ±29.6 6.239 .006**
Bachelor’s Degree 256 73.1 No 146.03±26.8
Master’s Degree 36 10.3
PhD 16 4.6

Working units
Table 4
Triage 28 8
Multiple linear regression model.
Labor room 25 7.14
Emergency Room 90 25.71 Unstandardized Standardized T Value
Intensive Care Unit 60 17.14 Coefficients Coefficients
Operating Room 65 18.57
B В
Inpatients wards 82 23.43
Age (year) 0.199 0.238 3.867 0.021*
Years of Experience
Marital status 0.152 0.199 3.012 0.027*
1-5 years 226 64.6
Educational 0.297 0.347 6.735 0.005**
6-10 years 72 20.6
level
11-15 years 38 10.9
Experience 0.366 0.486 5.976 0.008**
More than15 years 14 4
Training 0.208 0.302 6.239 0.006**
Mean SD 5.62±2.68
courses
Training courses related to patient safety ANOVA
Yes 134 38.3 Model Df. F P. value
No 216 61.7 Regression 5 4.286 0.009**

Mean age of participants was 27.12 years (SD = 5.37). Mean years of experience a. Dependent Variable: Attitude to patient safety
was 5.62 (SD = 2.68). A total of 74.9% of the studied population was female and b. Predictors: (constant) Age, marital status, educational level, experience, and
51.4% were married. 73.1% have a bachelor degree and 38.3% had previous training courses.
patient safety training. See Table 1.

3
S.A. Salih et al.
investigated patient safety attitudes among cardiology and cardiovas­
cular surgery nurses in a Turkish facility. The study further revealed that
nurses’ attitude scores in the six domains were lower than those for the
rest of the world recorded in the literature. Studies reported mean safety
attitude scores above 75% worldwide (Lee et al., 2010). In this study, the
highest score was observed in the teamwork domain: 42.61 (SD = 6.90).
This finding does, however, match those of Tunçer Ünver and Harmanci
Seren (2018), who reported negative attitudes among midwives, nurses,
and physicians.
The domain with the lowest score was stress recognition: 14.6 (SD =
3.65). This finding might be explained by the different nature of this
domain, as it requires nurses to assess their own internal stressors.
Future studies should consider this difference when interpreting findings
related to this domain. Our findings are congruent with those of Rafto­
poulos and Pavlakis (2013) and Henry, Hunt, Kroetch, and Yang (2012)
in that the lowest attitude score was in the domain of stress recognition.
The safety climate score was 17.49 (SD = 4.09). The safety climate is
described as the perception of strong and constructive organizational
commitment to safety. This domain includes issues related to reporting
errors and working according to rules or guidelines (Alqahtani & Evley,
2020). Our result is consistent with a previous study (Gambashidze,
Hammer, Ernstmann, & Manser, 2020) which identified the safety
climate as one of the weakest factors.
The job satisfaction items score came in at the second level in the
domains: 34.32 (SD = 9.01), which was similar to the results in the
studies of Zhao et al. (2019) and Bitan, Moran, and Harris (2019).
On the other side of the analysis, based on Chi-square and ANOVA
test results, there were no statistically significant differences between
the mean positive attitude scores in the dimensions of gender and place
of work; however, educational level, years of experience, and training
courses had a strong effect on nurses’ attitudes toward patient safety (p-
value < 0.01). This result is similar to that of Nie et al. (2013), who
found a significant difference in the perception of patient safety culture
and educational level. In contrast, our findings differ from those re­
ported by Bahar and Önler (2020), that years of job experience did not
affect attitudes to patient safety. Other studies reported that younger
nurses’ attitude scores were lower than those of their counterparts who
had more experience (Danielsson, Nilsen, Rutberg, & Årestedt, 2019;
Dunstan & Coyer, 2020), but this was not supported by our study. A
possible explanation for this finding is that nurses with less experience
have less knowledge. Finally, age and marital status had a slight pre­
dictive effect on nurses’ attitudes (p-value < 0.05).
7. Conclusion
This study provides an overview and explanation of nurses’ attitudes
to patient safety in Mansoura University Hospital. We assessed attitudes
in six domains: job satisfaction, teamwork, safety climate, perception of
management, stress recognition, and working conditions. The research
revealed that these Egyptian nurses had a disappointing attitude toward
patient safety. Educational level, years of experience, and training
courses related to patient safety were significant predictors of their at­
titudes. However, age and marital status were less significant, and there
was no significant association between total attitude scores and gender
or working unit (p-value > 0.05). These findings raise a red flag about
the status of nurses’ attitudes toward patient safety and the need to
mandate training programmes to improve them. They also highlight the
effect of educational level, years of experience, and training courses.
8. Recommendations
This study highlights the importance of education and training for
nurses at the postgraduate level, in order to reduce the rate of accidents
and their consequences in clinical settings. Moreover, our findings
should urge decision makers in the educational system to revise the
nursing curriculum. Giving more focus on patient safety in the
4
International Journal of Africa Nursing Sciences 14 (2021) 100287
undergraduate courses would help to encourage nurses’ positive
attitude.
9. Limitations of the study
This research has some limitations. The sample was not random and
affects the generalizability of the findings. Future studies are recom­
mended to replicate this one, with a random sample from different na­
tionalities and geographical areas. Also, the data was mostly collected
on the day shift, where often have a higher work load, affecting the
validity of the findings. Future studies is encouraged to approach nurses
working different shifts.
10. Financial support and sponsorship
There was no financial support or sponsorship.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgments
We extend our thanks to all the participants for their assistance in
carrying out our study.
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