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Assessment of patient safety climate in accident and emergency departments

in Cyprus

Article in Scripta Scientifica Salutis Publicae · January 2015

DOI: 10.14748/sssp.v1i2.1355

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 ORIGINAL ARTICLES

ASSESSMENT OF PATIENT SAFETY CLIMATE IN

ACCIDENT AND EMERGENCY DEPARTMENTS IN CYPRUS
Christoforos Nicolaides1, Antoniya Dimova 2
1
Nicosia General Hospital, Cyprus
2
Department of economics and health care management, Faculty of Public health,
Medical University of Varna

ABSTRACT
INTRODUCTION: The aim of the study is to evaluate safety climate in the accident and emergency (A&E)
departments in Cyprus. This would help for an assessment of the general patient safety environment and
could be used as a starting point for the establishment of a quality management system, which ensures pa-
tient safety.
MATERIAL AND METHODS: A sociological survey using Safety Attitudes Questionnaire (SAQ) was
conducted with 284 employees (68%) working at the A&E departments in five public hospitals in Cyprus
in 2013 and 2014. SAQ consists of 30 statements, examining safety climate in six domains: teamwork, safe-
ty, job satisfaction, working conditions, stress and perceptions of management, which respondents have to
agree or disagree with.
RESULTS: Safety climate in the A&EDs in Cyprus is questionable since none of the safety climate dimen-
sions received a positive assessment. Job satisfaction is highly rated, while stress recognition received the
lowest assessment. Although the majority of the respondents declared that they would feel safe being treated
at their hospital as patients, a few of the surveyed think that medical errors are handled appropriately. This
study found a strong reverse correlation between work intensity and personnel’s general perceptions of safe-
ty climate. In those departments, which admit more patients per staff member annually, personnel’s percep-
tions of safety climate are more negative.
CONCLUSION: The lack of adequate managerial support and commitment to safety issues can be consid-
ered as key determinants of the weak safety culture in the A&EDs in public hospitals in Cyprus.
Keywords: safety climate, patient safety, accident & emergency, quality of care, Cyprus

Address for correspondence: INTRODUCTION

Antoniya Dimova-Yordanova Patient safety is considered as one of the most
Department of economics and health care management important and fundamental dimensions of quality of
Faculty of Public health, Medical University of Varna
care, which is included in or influenced by the other
55 Marin Drinov Str.
9002 Varna, Bulgaria healthcare quality dimensions such as appropriate-
e-mail: ant_dimova@abv.bg ness, effectiveness, efficiency, and timeliness.
Replacing the old initiatives that were focused
Received: October 9, 2015 on human error and human behavior (1), the con-
Accepted: December 1, 2015 temporary approaches to patient safety assurance

Scripta Scientifica Salutis Publicae, vol. 1, No. 2, 2015, pp. 21-27

Copyright © Medical University of Varna 21
Assessment of patient safety climate in accident and emergency departments in Cyprus
are oriented toward the examination of management
practices, organizational structures and system pro-
cesses which negatively influence performance (2).
In the field of patient safety, developing safety
culture is increasingly recognized as the most signif-
icant approach to improve patient safety. Successful
organizations cultivate a climate where the employ-
ees’ decisions are in agreement with organization’s
vision and mission and provide such an environment
enabling the demonstration of knowledge, skill and
abilities by the members’ team (3). At the manage-
ment level, managers should employ initiatives that
promote safety culture in the organization by rein-
forcing the empowerment of the employees and en-
couraging them to act preventively and promptly re-
port potential threats (4).
The terms ‘safety culture’ and ‘safety climate’
are usually interchangeably used in literature and
are widely perceived as concepts rooted in the poli-
cies, procedures, and practices specific to safety (3).
Also, there has been substantial difficulty in differ-
entiating safety culture and safety climate as well as
considerable debate in the effort to define them, thus
various definitions for these two terms can be iden-
tified (5). In broad terms the climate is considered as
the observable or the measurable part of the culture
(4), whereas culture is described as less tractable and
complex concept (6).
While ‘safety culture’ refers to behavioral (e.g.
safety-related activities, actions and behaviors of em-
ployees) and situational aspects of a company (e.g.,
organization’s policies, operating procedures, man-
agement systems, control systems, communication
flows and workflow systems), ‘safety climate’ re-
fers to the psychological characteristics of employ-
ees such as their perceptions, attitudes and values on
safety aspects within the organization (7). Although,
common aspects can be recognized in both concepts,
‘safety climate’ seems to reflect the underlying cul-
ture of the workforce, thus an apparent distinction
between them is that they operate on different levels
(8). The term ‘safety climate’ encompasses the specif-
ic elements of safety culture that can be observed and
measured at a given moment in time, thus, it is often
characterized as a ‘snapshot’ of culture (9).
The measurement of safety climate can identify
areas of organizational failures or weaknesses at all
Scripta Scientifica Salutis Publicae, vol. 1, No. 2, 2015, pp. 21-27
22
levels and provide useful information for the purpos-
es of patient safety and quality of care improvement.
Numerous past research, mostly in industry,
have used plethora of dimensions in order to exam-
ine the safety climate (8). Many of these dimensions
are applicable to health care as well such as team-
work, perception of management, job satisfaction,
stress recognition, and working cognitions. Person-
nel attitudes and perceptions about these dimensions
both reflect and influence patient safety reality in the
organization.
Arguably, strategies for health care quality as-
surance and improvement are still not developed and
implemented in Cyprus neither by the Ministry of
Health nor by hospitals, and quality control is prac-
tically absent (10). While there is no quality mea-
surement system developed in Accident and Emer-
gency departments in Cyprus, this study aims at as-
sessment of workforce’s attitudes towards safety and
quality. Such assessment is expected to clarify the
way employees experience their working environ-
ment and to identify lacks in safety climate as well as
to reveal any system’s failures or weakness that might
exist.
Thus, the specific AIM of the study is to eval-
uate safety climate in the accident and emergen-
cy (A&E) departments of five regional public hospi-
tals in Cyprus as a prerequisite for its future develop-
ment and improvement. The achievement of this aim
would help for indirect assessment of the general pa-
tient safety environment and quality assurance level
in the researched departments. It would also be use-
ful as a starting point for the establishment of a qual-
ity management system which ensures patient safety.
The object of the study is the A&E departments’
personnel in five public hospitals in Cyprus. Reasons
behind the selected object are related to specific char-
acteristics of these departments which have signifi-
cant impact on patient safety assurance, such as a
wide range of problems falling into the categories of
illness, trauma and mental health, urgent and emer-
gency aspects of illness and injury, uncertainty, and
high risk environment.
The subject of the study is personnel’s atti-
tudes and perceptions regarding specific character-
istics of patient safety and safety climate in the A&E
departments.
Copyright © Medical University of Varna
 Christoforos Nicolaides, Antoniya Dimova

MATERIAL AND METHODS was higher for nurses (83.0%) than for physicians
The general approach to achieve the aim of the (16.7%). The sample size represented 68% of the em-
study is based on the understanding that safety cli- ployees of the five A&EDs (73% of the nurses and
mate, as part of the organizational culture, could be 51% of the physicians). Means, percentages, standard
assessed through sociological methods. In order to deviation, and correlation were computed using Mi-
use appropriate tools for safety climate assessment, a crosoft Excel. Safety climate attitudes were subjects
broad literature review was made. of comparative analyses regarding respondents’ and
The Greek version (11) of the Safety Attitudes A&E departments’ characteristics.
Questionnaire (SAQ) (12) was selected as a tool for
RESULTS AND DISCUSSION
the sociological research.
The overall results from the sociological survey
SAQ is an anonymous self-administered ques-
indicate that the safety climate in the A&EDs in Cy-
tionnaire; its short version consists of 30 statements
prus is questionable since none of the safety climate
which respondents have to agree or disagree with
dimensions received a positive assessment of ≥75.
and four questions exploring demographic charac-
Job satisfaction is highly rated, similarly to all com-
teristics of the sample. Statements examine the safety
parable studies (11,13,14), while stress recognition re-
climate of an organization by eliciting the health care
ceived the lowest assessment (Table 1). This means
providers‘ attitudes to six domains: teamwork, safe-
that the majority of nurses and physicians from the
ty, job satisfaction, working conditions, stress, and
five A&EDs like their job, but at the same time, they
perceptions of management. Assessment is based on
experience significant stress at work.
the five-point Likert’s scale (1 = disagree strongly; 2
Looking at the detailed results (Table 2), the
= disagree slightly; 3 = neutral; 4 = agree slightly; and
statement ‘I like my job’ included in the work sat-
5 = agree strongly) converted to continuous variables
isfaction dimension, is the only one which gained a
such as: strongly disagree = 0; disagree = 25; neu-
positive assessment (84.97). Approximately 85% of
tral = 50; agree = 75; and strongly agree = 100. While
the respondents declare their strong commitment
some statements are negative (all stress recognition
with this statement. This fact can be considered as
statements and some others), their score is reversed
a good starting point to enhance safety climate but
so that higher score always represents more positive
it requires further leadership commitment in iden-
attitude. “Positive safety attitude” is granted to those
tifying and eliminating system weaknesses, which
dimensions which have mean score equal or higher
caused the lower scores of the other job satisfaction
than 75.
factors. Such an approach is essential for better out-
A structured sociological survey, using SAQ,
comes, since there is an evidence for correlation be-
was conducted with 284 employees (217 nurses and
tween job satisfaction and patient safety (15). Howev-
67 doctors) working at the A&E departments in five
er, the low to moderate scores of the other job satis-
public hospitals in Cyprus (Nicosia, Limassol, Lar-
faction dimensions show that patient safety is at risk.
naca, Paphos, and Ammochostos) in 2013 and 2014.
This underlines the need for improvements of those
From all 284 distributed questionnaires, 202 (71.12%)
components of the working environment, which will
were completed, 98% of which were accepted as val-
enhance safety culture. There is a general agreement
id. A&ED staff response rate varied from 48.07 to
that such an improvement presupposes hospital ad-
88.57% among the five hospitals. The response rate
ministration commitment and support.
Table 1. General assessment of safety climate domains, total score

JS TW SC WC POM SR

Assessment 67,39 (±3,8) 58,52 (±3,8) 58,45 (±3,7) 52,05 (±3,8) 50,06 (±4,2) 33,39 (±4,7)

Legend: Job satisfaction (JS), Teamwork climate (TW), Safety climate (SC), Working conditions (WC), Perceptions of management
(POM), Stress recognition (SR)

Scripta Scientifica Salutis Publicae, vol. 1, No. 2, 2015, pp. 21-27

Copyright © Medical University of Varna 23
Assessment of patient safety climate in accident and emergency departments in Cyprus

Table 2. Results by domains and statements

Total % of
score/ respondents
Safety Climate Domains and Statements
mean who slightly or
value strongly agree
Safety Climate (SC)
SC1. I would feel safe being treated here as a patient 65,4 60,6 (±6,8)
SC2. Medical errors are handled appropriately in this A&Ed . 58,83 42,92 (±6,9)
SC3. I receive appropriate feedback about my performance 54,92 43,93 (±6,9)
SC4. In this A&Ed , it is difficult to discuss errors. 52,27 34,84 (±6,6)
SC5. I am encouraged by my colleagues to report any patient safety concerns I
58,71 49,49 (±7)
may have.
SC6. The culture in this A&Ed makes it easy to learn from the errors of other. 57,07 44,94 (±6,9)

SC7. I know the proper channels to direct questions regarding patient safety in this A&Ed . 60,35 55,05 (±6,9)
Teamwork (TW)
TW1. Nurse input is well received in this A&Ed 52,65 40,9 (±6,8)
TW2. In this A&Ed it is difficult to speak up if I perceive a problem with patient care 52,77 37,37 (±6,7)
TW3. Disagreements in this A&Ed are resolved appropriately (ie, not who is right, but
53,15 35,85 (±6,7)
what is best for the patient).

TW4. I have the support I need from other personnel to care for patients 64,89 58,08 (±6,9)
TW5. It is easy for personnel in this A&Ed to ask questions when there is something that they do
not understand..
69,94 68,68 (±6,5)

TW5. The physicians and nurses here work together as a well-coordinated team. 57,7 52,52 (±7)
Perceptions of Management (POM)
POM1. Hospital administration supports my daily efforts. 37,37 22,22 (±5,8)
POM2. Hospital management does not knowingly compromise the safety of
52,14 34,34 (±6,6)
patients.
POM3. The levels of staffing in this clinical area are sufficient to handle the
56,43 45,45 (±6,9)
number of patients.
POM4. I am provided with adequate, timely information about events in the
54,29 40,9 (±6,8)
hospital that might affect my work.
Job Satisfaction (JS)
JS1. I like my job. 84,97 85,35 (±4,9)
JS2. Working in this hospital is like being part of a large family. 67,8 62,12 (±6,8)
JS3. This hospital is a good place to work. 60,85 52,02 (±7)
JS4. I am proud to work at this hospital. 62,75 51,51 (±7)
JS5. Moral in this A&Ed area is high. 60,47 51,01 (±7)
Working Conditions (WC)
WC1. This hospital does a good job of training new personnel. 52,52 39,89 (±6,8)

Scripta Scientifica Salutis Publicae, vol. 1, No. 2, 2015, pp. 21-27

24 Copyright © Medical University of Varna

WC2. All the necessary information for diagnostic and therapeutic decisions is
routinely available to me.
WC3. This hospital constructively deals with problem physicians and employees.
WC4. Trainees in my discipline are adequately supervised.
Stress Recognition (SR)
SR1. When my workload becomes excessive, my performance is impaired.
SR2. I am less effective at work when fatigued.
SR3.I am more likely to make errors in tense or hostile situations
SR4. Fatigue impairs my performance during emergencies (e.g. emergency
resuscitation and seizure).
The statement that gained the second high-
est assessment refers to the opportunity for respon-
dents to ask questions any time there is something
that they do not understand, included in the team-
work dimension (Table 2, statement TW5). However,
it is more difficult for the employees to speak up in
case they perceive a problem with patient care (Table
2, statement TW2). This result corresponds with the
lowest rate of errors discussion among the statements
exploring safety climate (statement SC4).
While teamwork is well documented as a core
element of patient safety (16,17), unsatisfactory re-
sults from this study trigger the need for further in-
vestigation of the underlying causes for the low as-
sessment of all teamwork dimension items. The most
impressive lack of freedom to speak up in case of con-
cerns regarding care and the difficulties to discuss
errors hamper safety climate most significantly. This
explains the personnel’s negative attitude regarding
appropriateness of medical errors management.
Although the majority of the respondents de-
clared that they would feel safe being treated at their
hospital as patients (statement SC1), a few of the sur-
veyed think that medical errors are handled appro-
priately in the respective A&ED (statement SC2).
In addition, the general perception of manage-
ment and some working conditions underline the
need of improvement of managers-personnel rela-
tions regarding administrative support, problems
solving and feedback. A small number of respon-
dents think that the hospital constructively deals
with problem physicians and employees (working
conditions dimension, statement WC3) and that the
Scripta Scientifica Salutis Publicae, vol. 1, No. 2, 2015, pp. 21-27
Copyright © Medical University of Varna
Christoforos Nicolaides, Antoniya Dimova
54,79 40,4 (±6,8)
43,43 27,77 (±6,2)
57,44 41,41(±6,9)
34,72 20,7 (±5,6)
32,57 15,65 (±5,1)
25,25 13,13 (±4,7)
41,04 55,05 (±6,9)
hospital administration supports their daily efforts
(perception of management dimension, statement
POM1). Communications beyond the official chan-
nels should be developed as well.
Stress recognition shows that the personnel ac-
knowledge the impact of fatigue, overload, and emer-
gencies to patient safety (Table 2).
There are some differences in attitudes between
respondents from different specialties, age groups,
length of professional service and service in A&ED,
gender. Physicians have more positive attitudes than
nurses in all dimensions, except stress recognition.
They rated teamwork dimension significantly higher
than nurses did.
Remarkable is the fact that for all six dimen-
sions, the staff with the most years in profession and
most years working in an A&ED gave the most pos-
itive assessment. One exception was stress recogni-
tion, which was the highest among the respondents
with professional experience between 6 and 20 years.
Less stressed are those with up to 5 and above 21
years of professional experience.
Safety climate attitudes are similar for men and
females. However, males express a more positive atti-
tude (51.47) than females (48.69).
Comparative analyses between the researched
A&EDs show that none of them achieved a positive
score (≥75) towards patient safety and staff percep-
tions of safety climate.
The safety climate was assessed most positively in
Ammochostos Hospital, while the worst safety climate
attitudes were expressed in Paphos Hospital (Table 3).
25
Assessment of patient safety climate in accident and emergency departments in Cyprus

Table 3. Safety climate dimensions by hospital

Ammochostos Limassol Paphos Nicosia Larnaca

Safety climate (SC) 73,57 56,72 52,56 57,65 56,85
Teamwork (TW) 73,83 53,75 52,86 58,92 61
Perceptions of Management (POM) 63 45,41 47,26 49,77 52,5
Stress Recognition (SR) 41,75 37,18 35,54 35,26 44,5
Working Conditions (WC) 67,50 51,56 52,56 50,66 47,75
Job Satisfaction (JS) 87,80 64,66 61,28 64,01 68,80
Overall Mean value 67,92 51,55 44,36 52,71 55,23

Generally, analyzing each safety climate di-
mension, it is obvious that their scores are ranging
more or less at the same levels. However, the Ammo-
chostos A&ED is the only one which reached a pos-
itive score ≥75 for one dimension and two more di-
mensions reached just below 75, which is considered
satisfactory enough regarding safety attitudes. Pro-
fessionals, working in Ammochostos A&ED were
most satisfied with their job (87.80). Stress recogni-
tion dimension gained its highest score from Larna-
ca respondents, showing a more acknowledgeable at-
titude towards stressful situations.
Patient safety was very positively assessed in
Ammochostos hospital, where a big part of respon-
dents (96%) would feel safe being treated there as
patients.
This study found a strong reverse correlation
(-0.72) between work intensity and personnel gener-
al perceptions of safety climate. In departments with
more patients per staff member annually, personnel’s
perceptions and attitudes towards safety climate are
more negative.
CONCLUSION
The lack of adequate managerial support and
commitment to safety issues, assessed through the
absence of formal policies and safety guidelines, can
be considered as key determinants of the weak safety
culture in the A&EDs in public hospitals in Cyprus.
Issues of teamwork, collaboration and staffing affect
daily practice and the overall safety climate as well. A
fact with positive meaning is that the personnel ex-
perience high job satisfaction in general. This can be
used as a base for improvements and development.
Variations in safety climate in the researched
A&EDs in such a small geographic area as Cyprus
suggest that problems exist not only at a national but
at a local level as well, and this indicates the need for
further investigation.
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