Safety Science 147 (2022) 105624

Contents lists available at ScienceDirect

Safety Science
journal homepage: www.elsevier.com/locate/safety

Review

Safety culture, safety climate, and safety performance in healthcare

facilities: A systematic review
Intan Suraya Noor Arzahan a, b, Zaliha Ismail a, *, Siti Munira Yasin a
a
Dept. of Public Health Medicine, Faculty of Medicine, Universiti Teknologi Mara Malaysia, 47000 Sungai Buloh, Selangor, Malaysia
b
Ministry of Health Training Institute (ILKKM), Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia

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

Keywords: Numerous studies, especially in high-risk industries, have looked into how safety culture might help a company
Systematic Review improve its safety performance. However, healthcare facilities are still in their early stages of safety performance
Safety culture or climate development. A systematic review (SR) of Scopus, Web of Science, Dimensions, ScienceDirect, and Google
Safety Performance
Scholar, was conducted using the Preferred Reporting Items for Systematic Reviews (PRISMA) technique. The
Health Professional
purpose is to look into the link involving safety culture or climate and safety performance in healthcare facilities.
Healthcare Facilities
A number of keywords ‘safety culture’, ‘safety climate’, ‘safety performance’, ‘injury’, ‘incident’, ‘healthcare’,
‘hospital’, ‘clinic’, ‘health office’, ‘health division’, and ‘health authority’ were chosen by researchers in this SR.
The inclusion criteria were (1) studies in healthcare facilities involving safety culture or safety climate-linked
with safety performance, (2) English language, and (3) research published in peer-reviewed journals within
five years (2016 to 2020). The EPHPP-Quality Assessment Tool was used to assess the quality of the studies. The
influence of safety culture, climate, and safety performance in 11 research was reviewed by researchers in the
current paper. Only one study was rated as strong quality, six of the studies were rated as moderate quality, and
the rest were rated as weak quality. The EPHPP quality assessment tool dictionary aided evaluation of article
bias. The proactive measure is favored among researchers in healthcare and has a significant relationship with
safety culture or safety climate. Despite the importance of this field, quality research is still insufficient, ac­
cording to our evaluation. Additional research is needed to explain the link between the variables evaluated,
particularly in healthcare facilities and other low-risk industries.

1. Introduction
The terms “safety culture” and “safety climate” are often used in the
literature to refer to the nature of an organization’s policies and the
attitudes of its employees regarding safety issues. In certain studies, the
words “safety culture” and “safety climate” have been used inter­
changeably. Researchers found numerous definitions in the literature,
but researchers have agreed upon no one description. Some indicators’
explanations are preferred over others in this regard. Safety culture is
most commonly referred to as “the result of individuals and groups’
beliefs, attitudes, competencies, and behavior patterns. It defines the
commitment to and the style and efficiency of an organization’s safety
and health (S&H) management” (International Atomic Energy Agency,
1991). Safety climate, on the other hand, is a more superficial
perspective. It has also been considered the measurement of safety
culture and how the people in one’s organization perceive safety in their
work environment (Zohar, 1980) Later, safety climate was defined as
how individuals view workplace safety rules, procedures, and practices
(Griffin and Neal, 2000) There is currently no consensus on the di­
mensions of the safety climate. It may vary from one industry to another
(Alruqi et al., 2018) The difference between safety culture and safety
climate is that safety culture relates to an organization’s set of values. In
contrast, safety climate refers to the effect of environmental and orga­
nizational factors on these values. Both (Guldenmund, 2000) and
(Zohar, 2010) said that safety culture is a fundamental concept in the
new strategy to enhancing the results of safety performance. Safety
culture aims to create a good environment where employees are aware
of hazards and accident prevention (He et al., 2012; Zin and Ismail,
2012).
However, there is no final consensus in the literature on the concept
of safety performance. The majority of academics determine the mean­
ing based on their own experiences (Yu-Jung et al., 2013; De Koster

* Corresponding author at: Dept. of Public Health Medicine, Faculty of Medicine, Universiti Teknologi Mara Malaysia, 47000 Sungai Buloh, Selangor, Malaysia.
E-mail address: zaliha78@uitm.edu.my (Z. Ismail).

https://doi.org/10.1016/j.ssci.2021.105624
Received 15 June 2021; Received in revised form 11 October 2021; Accepted 30 November 2021
Available online 11 December 2021
0925-7535/© 2021 The Authors. 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/).
I.S. Noor Arzahan et al.
et al., 2011), for example, defined safety performance as an organiza­
tion’s capacity to avoid work-related accidents or injuries. Because of
their impact on organizational safety performance, safety culture and
climate have been influential in recent decades.
A substantial amount of study has been conducted to examine the
relationship between safety culture and climate and their effect on safety
outcomes, including safety performance. Numerous studies, particularly
in high-risk sectors, have investigated how safety and safety culture may
assist an organization in improving its safety performance. (Cheyne and
Cox, 2000; Kasim, Hassan, Hamid, Emami, & Danaee, 2019). The
aviation sector started as a reactive industry and has thrived as a result
of positive underlying attitudes; the oil and gas industry has improved as
a result of being more systematic and calculative in its approach. Both
are convergent in that they are trying to fix their faults in order to
become more proactive. In light of this awareness, the healthcare system
is still in the early phases of growth regarding safety culture issues,
which is a good sign. Review studies in this area have also been pub­
lished in recent years, yet; there has been little review study on the in­
dicator metric of these three terms: safety culture, safety climate, and
safety performance, particularly in healthcare settings. As a result, this
paper summarizes all relevant studies conducted in healthcare in­
stitutions in order to evaluate the evidence demonstrating a connection
between safety culture, safety climate, and safety performance. The
organization of this systematic review is tailored to answer the critical
questions of interest as follows: (1) What is the dimension for safety
culture, safety climate, and safety performance in healthcare facilities?.
(2) What is the method of assessment that has been conducted?. (3)
What is the relationship between these variables?.The following is the
structure of the paper: Section 2 highlights the objectives of the review.
The methodologies utilized in the investigation are discussed in Section
3. Section 4 give the findings from the analysis. Section 5 has a discus­
sion, Section 6 highlights limitation, while Section 7 summarizes and
concludes the work.
2. Objective
This systematic review aims to determine the indicator of safety
culture, climate, and performance in healthcare institutions, as well as
the evidence connecting safety culture, climate, and performance. The
solution needs to be broken down into feasible elements to form a model
that can produce better safety performance. Suppose we refer to previ­
ous studies and theories related to safety performance. In that case, the
safety culture or safety climate factor is one of the things that is often
given attention because of its role that helps a lot to improve safety
performance (De Koster et al., 2011; Fernández-Muñiz et al., 2014;
Lingard et al., 2012; Mellott, 2021; Nielsen et al., 2008; Rajabi et al.,
2020; Wachter and Yorio, 2014; Xu et al., 2020; Zwetsloot et al., 2017).
Researchers looked at the elements or variables that enhance safety
performance in the healthcare industry as part of this study, hoping that
this information will be useful to authorities (Public Services and Stat­
utory Authorities) in planning and identifying necessary safety culture
elements to improve safety performance. Besides that, it aims to meet
the objectives of the Malaysian Occupational Safety and Health Master
Plan 2016–2020 , to inculcate a safe and healthy work culture for the
well-being of employees, employers, and the country as a whole.
3. Method
3.1. Eligibility criteria
Particular inclusion and exclusion criteria are established to answer
the research question: What evidence exists to show safety culture or
climate link to safety performance in healthcare facilities?. First, only
article journals containing empirical data were chosen, which means
review articles, book series, books, book chapters, and conference pro­
ceedings are all omitted. Second, to prevent ambiguity or difficulty in
2
Safety Science 147 (2022) 105624
translation, the search attempts eliminated non-English publications
and concentrated solely on English-language content. Finally, a five-
year timeframe has been chosen (between 2016 and 2020).
3.2. Search strategy
The researcher used the PRISMA Statement to guide the review, and
it is often utilized in the safety and health field. The PRISMA Statement
also enables a thorough search of topics linked to the interaction be­
tween safety culture, climate, and performance. The researchers selected
five primary journal databases in this study – Scopus, Web of Science
(WoS), Science Direct, Google Scholar, and Dimensions. The keywords
‘safety’, ‘safety culture’, ‘safety climate’, ‘safety performance’, ‘injury’,
‘incident’, ‘healthcare’, ‘hospital’, ‘clinic’, ‘health office’, ‘health divi­
sion’, and ‘health authority’ were chosen in this systematic review. Since
the study focuses on healthcare facilities and only on health pro­
fessionals’ safety and health, the searching strategy did not include the
‘patient safety’ term. Provided below is a search strategy sample from
the Web of Science (WoS) online database:
(AB= ((“safety” OR “safety culture*” OR “safety climate*”) AND
(“safety performance*” OR “incident*” OR “injury*”) AND (“healthcare”
OR “hospital*” OR “clinic*” OR “health office*” OR “health division*”
OR “health authority*”) NOT (“patient safety”)))
Fig. 1 depicts the procedures for selecting relevant publications for
the study. The review involved a systematic review method, identifi­
cation of targeted variables, and content analysis. The systematic review
process, which took place in December 2020, included a database search
to discover similar papers. Based on past research and thesaurus, key­
words linked to safety culture, climate, safety performance, and
healthcare were included. After the meticulous screening, 12 duplicated
articles were excluded at this step. 4615 articles were matched based on
title and keywords set. After the screening process, we were left with 175
articles. After analyzing the publications, the researchers chose 11 ar­
ticles based on their conformity with the selection criteria. These last
few articles have been reviewed and discussed. The efforts were
concentrated on specific research that provided answers to the specified
questions. In order to collect information, researchers began by reading
the abstracts, followed by the articles (in detail) to identify relevant
themes.
In the next step, start to identify variables. We also identified the
article’s features, such as the authors’ names, origin, publication year,
method of assessment chosen for each variable, and the study popula­
tion. Table 1 summarises these characteristics. In the last step of content
analysis, we explored the relationships between safety culture, climate
dimensions, and safety performance metrics. The link between each
variable is provided in Table 3. This link is presented based on statistical
analysis that has been conducted in the papers. There are two methods
to describe these relationships: either a positive or negative relationship
between variables.
3.3. Quality assessment
The selected study’s quality was assessed using the Quality Assess­
ment System for Effective Public Health Practices Project (EPHPP)
quality for quantitative studies, which looks at selection bias, study
design, confounders, blinding, data collection techniques, and drop-out
rate. Evaluation of article bias was aided by the EPHPP quality assess­
ment tool dictionary. Based on the individual ratings provided to each
dimension, each article’s quality was evaluated as strong, moderate, or
weak, according to the dictionary. The findings from each domain were
then pooled to provide a global rating. The studies were assessed as
poor-quality (two or more aspects were deemed weak), moderate-
quality (one aspect was deemed weak), and high-quality (no aspect
was rated as weak). The study’s quality was evaluated by all of the au­
thors separately (ISNA, ZI, and SMY). Disagreements and questions that
occurred throughout the review process were resolved during
I.S. Noor Arzahan et al. Safety Science 147 (2022) 105624

Fig. 1. Literature search strategy and selection for included studies (n = 11).

Table 1
Selected Journal Article.
Country Studies Type of Relationship Method of Assessment Respondent

Safety culture & Safety Safety Performance

Climate

Iran (Ghasemi, Aghaei, Askaripoor, & Safety Climate and Self-reported Safety compliance and Hospital nurses
Ghamari, 2020) Safety Performance Questionnaire participation
China (Xu et al., 2020) Safety Climate and Self-reported Safety compliance and Healthcare employees
Safety Performance Questionnaire participation
Canada (McGhan, Ludlow, Rathert, & Safety Climate and Self-reported Number of injuries, job Healthcare practitioners
McCaughey, 2020) Safety Performance Questionnaire satisfaction, stress & turnover
intent
Egypt (Alghalban et al., 2020) Safety Climate and Self-reported Number of incidents-Sharps Healthcare workers
Safety Performance Questionnaire Injuries
USA (Vogus, Ramanujam, Novikov, Safety Climate and 16 items Self-reported Experience on burnout Hospital nurses
Venkataramani, & Tangirala, 2020) Safety Performance Questionnaire
Turki Uzuntarla et al. (2020)) Safety Culture and 18 items Self-Reported Safety behavior Healthcare practitioners
Safety Performance Questionnaire
USA (Quach et al., 2020) Safety Climate and Self-reported Adverse events Nurses, nursing assistants,
Safety Performance Questionnaire and clinicians/specialists
Indonesia (Ismara, Husodo, Prabandari, & OSH Climate and OSH Self-reported Safety behavior Hospital nurses
Hariyono, 2019) Performance Questionnaire,
Interview & observation
Nigeria (Mashi, 2017) Safety Culture and Self-reported Safety compliance and Hospital nurses
Safety Performance Questionnaire participation
USA (Cook, Slade, Cantley, & Sakr, 2016) Safety Climate and Self-reported Injury rates Healthcare practitioners
Safety Performance Questionnaire
Israel (Isaak, Vashdi, Bar-noy, Kostisky, & Safety Climate and Self-reported Number of incidents Healthcare practitioners
Hirschmann, 2016) Safety Performance Questionnaire

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I.S. Noor Arzahan et al. Safety Science 147 (2022) 105624

discussions. performance.

4. Results 5. Discussion

4.1. Study selection
After reviewing the abstracts and full papers, 11 suitable publica­
tions were chosen for inclusion in the review. We discovered that 27.2%
(n = 3) of the study were performed in the United States, 9.1% (n = 1) in
Egypt, 9.1% (n = 1) in Turkey, 9.1% (n = 1) in Canada, 9.1% (n = 1) in
Nigeria, 9.1% (n = 1) in Indonesia, 9.1% (n = 1) in Israel, 9.1% (n = 1)
in Iran, and 9.1% (n = 1) in China. Table 1 lists the features of the ar­
ticles that were chosen. The target respondent in healthcare facilities, as
well as the safety climate, safety culture, and safety performance eval­
uation methods, are among these features.
This systematic literature review provides new empirical evidence
about the safety culture, safety climate, and safety performance rela­
tionship in the healthcare industries. The quality evaluation of the ar­
ticles revealed that 64% (7 out of 11 research) of the included studies
were conducted moderately or strongly. This fact gives us confidence
that the conclusions of this literature study are less skeptical than in the
past assessments of the link between the safety culture, safety climate,
and safety performance (Aburumman et al., 2019; Kalteh et al., 2021; Vu
and Cieri, 2014).
5.1. Safety culture or climate dimension

4.2. Study characteristics
Table 1 summarizes the study characteristics of the 11 eligible
studies. The tables provide information on study locations, types of re­
lationships, method of assessment, and target respondents found in each
study.
4.3. Quality assessment
Table 2 summarizes the quality of the 11 studies. The overall score at
the bottom of the table reveals that all studies scored strongly in terms of
selection bias (100%), data collection method (100%), and moderate in
terms of participant blinding (100%). Most studies scored moderately in
confounders (55%) and weak in research design (82%). Meanwhile,
there is a similar percentage for drop-outs in the studies and a similar
percentage for weak and moderate (36%). In terms of overall quality,
9% of the studies were high quality, 55% were of moderate level, and
36% were of low quality.
4.4. The type of variables’ relationship
The dimensions of the instrument in these surveys were established
depending on the aims of the study. However, the example of primary
aspects of the safety climate outlined by Xu et al. (2020) is such as
management commitment, organizational habits, safety engagement
and communication, safety equipment, housekeeping, safety training,
and rewards. Thus, in Table 4, we displayed the selection of the most
frequently recommended dimensions in assessing the safety climate or
culture. The most utilized dimensions for measuring healthcare facil­
ities’ safety culture were management commitment and safety resources
and availability of policies that reflect the organization’s commitment to
safety. This element is because safety resources such as allocated budget
from top management dedicated for safety-related is necessary espe­
cially organization under federal government (hospital etc.,) in ensuring
the progress and efforts to put towards safety in the healthcare facilities.
Furthermore, management commitments include designating at least
one competent member with safety training as secretary of the safety
committee and allowing workers to refuse to work in hazardous or un­
healthy conditions (Noor Arzahan et al., 2021) is vital to ensure the
organization is competent in handling safety-related issues and
problems.

Based on these selected publications, two studies based on these
chosen publications demonstrated a link between safety culture and
safety performance. The remaining nine studies investigated the link
between safety climate and safety performance. Six of the eleven pub­
lications used proactive methods to assess safety performance. Proactive
methods included safety behavior, safety compliance, and safety
engagement. Meanwhile, four of the studies used reactive measures such
as incidence and injury rates. Only one research combined reactive and
proactive methods to assess safety performance. Table 3 shows the di­
mensions, aspects, elements, indicators, or subscales of safety culture or
safety climate utilized in the studies and their connection to safety
5.2. Safety culture and safety climate – Method of assessment
As shown in Table 1, the variables are evaluated using various
techniques, including surveys, interviews, and observation. However, a
regular method of assessment chosen in the studied publications uses
self-reporting questionnaires. Researchers in the studied publication
designed questionnaires that were tailored to the targeted working
environment and subjects. Although employing a questionnaire to
analyze an organization’s safety climate or culture is straightforward, it
does have certain limitations. Because there is no clear consensus among
academics on the definitions of these terminologies, the categories of

Table 2
Quality assessment result against the effective public health practice project quality assessment tool
References Selection bias Design Confounders Blinding Data collection method Withdrawal & Global ratings
Drop-outs

(Ghasemi et al., 2020) Strong Weak Moderate Moderate Strong Moderate Moderate
Xu et al. (2020) Strong Moderate Strong Moderate Strong Strong Strong
McGhan et al. (2020) Strong Weak Strong Moderate Strong Weak Weak
(Alghalban et al., 2020) Strong Weak Moderate Moderate Strong Weak Weak
Vogus et al. (2020) Strong Weak Strong Moderate Strong Strong Moderate
Uzuntarla et al. (2020) Strong Weak Weak Moderate Strong Weak Weak
Quach et al. (2020) Strong Weak Moderate Moderate Strong Moderate Moderate
Ismara et al. (2019) Strong Weak Moderate Moderate Strong Strong Moderate
Mashi (2017) Strong Weak Moderate Moderate Strong Moderate Moderate
Cook et al. (2016) Strong Weak Moderate Moderate Strong Weak Weak
Isaak et al. (2016) Strong Moderate Weak Moderate Strong Moderate Moderate
Sum Weak (%) 0 9 (82) 2 (18) 0 0 4 (36) 4 (36)
Sum Moderate (%) 0 2 (18) 6 (55) 11(00) 0 4 (36) 6 (55)
Sum Strong (%) 11(1 0 0) 0 3 (27) 0 11(1 0 0) 3 (28) 1 (9)

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I.S. Noor Arzahan et al. Safety Science 147 (2022) 105624

Table 3 Table 4
Relationship between safety culture and safety climate dimensions and safety Prevailing dimensions of safety climate/culture in healthcare facilities.
performance measures Safety culture or safety climate dimension, aspect, element, Frequency
Studies Safety culture and Moderator/Mediator Relationship indicator, or subscale (%)
safety climate with safety
Management commitment/supervision/participation/involvement 8 (73%)
dimension, aspect, performance
Safety resources/policies/training 9 (82%)
element, indicator, or
Risk management/communication 6 (55%)
subscale
Safety rules/procedures/equipment/rewards 5 (45%)
Ghasemi Relationship among None Positive Worker’s involvement/participation 5 (45%)
et al. coworker
(2020) Communication
Management dimensions seem different for each type of organization. Thus, evalua­
supervision tion appears to be a formidable task. For example, the management
Working condition
commitment indicator assessment is varied and classically determined
Reporting of errors
Safety training by whether or not the organization’s senior management is dedicated to
Xu et al. Leaders’ commitment None Positive employee safety (Cook et al., 2016). Analyzing the common dimensions
(2020) to safety is crucial as the benefit is that it provides an essential indicator of how
Communication about far the organization’s safety culture has progressed. In the healthcare
safety
Safety education
industry, a quantitative approach to evaluating safety culture is the most
Worker safety often used method of investigation, with qualitative approaches being
precautions employed by only a small number. Most researchers devised a quanti­
Safety equipment and tative technique for measuring safety culture by examining workers’
housekeeping
perceptions using a five-point neutral mid-point Likert scale to indicate
Safety participation
and incentives their level of agreement or disagreement. This is a common technique
McGhan Safety knowledge None Positive used by past studies in construction, aviation, and manufacturing in­
et al. Safety policies dustries to prove its importance and relevance (Siti Fatimah Bahari,
(2020) Safety training 2011; Amirah et al., 2013; Abdullah et al., 2016).
(Alghalban Communication None Positive
et al., Management
2020) supervision
Working environment 5.3. Safety performance – The assessment indicators
Reporting of errors
The safety system in The type of industry being researched has a significant influence on
place
Vogus et al. Top management None Positive
the safety performance indicators used. Over time, conceptual models
(2020) commitment for analyzing the organization’s safety performance have been pre­
Safety Resources sented. These models are based on industry type and records on acci­
Risk management dents, injuries, and risky practices. Related to this matter, Cooper and
Communication with
Phillips (2004) have categorized reactive (action taken after incidents
worker
Uzuntarla Safety awareness None Positive happened) and proactive measures (action taken to prevent incidents) as
et al. two groups of safety performance assessment. After that, it is up to the
(2020) researcher to decide which measures to use, and it is usually determined
Quach et al. Safety priorities None Positive by the assessment’s goal and the organization’s available resources.
(2020) Management
commitment to safety
Reactive measurements are preferable when assessing the influence of
Supervisor earlier organizational efforts to perform safety-related activities or
commitment comparing effects when the safety intervention is done (Sherratt and
Personal attitudes (Fred), 2012). Based on a study by Glendon and Litherland (2001),
toward safety
reactive measures were used widely in high-risk industries. However,
Environmental safety
Coworker interactions they highlighted the weakness of such measures as if ignoring risk ex­
around safety posures, lack of sensitivity toward the studied organization, question­
Ismara et al. Attitude Safety intention act as Positive able accuracy, and retrospection. On the other hand, most studies in
(2019) Norm the mediator of safety literature supported that proactive measures are commonly used to
Perceived behavioral climate and safety
control behavior
evaluate the state of the organization’s effort or progress in inculcating
Mashi Management Consideration of Positive safety practices to enhance performance. Proactive measures have also
(2017) commitment future safety Positive proven to boost employee motivation in safety and health (Zahoor et al.,
SOPs & regulations consequence (CFSC) Negative 2017); thus, it is most suitable to be selected in healthcare industries and
Pro-safety policies moderate relationship
other low-risk organizations.
between safety SOPs
& regulations and The incident rate calculation is the method commonly used to
safety participation represent reactive criteria in the scientific literature. However, proven in
Cook et al. Management/ None Positive other studies in higher-risk industries, the reactive measure does not
(2016) Supervisory appear to have sufficient accuracy. For instance, in the construction
contribution
Employee engagement
industry, contractors usually underreport the number of incidents due to
Activities for safety feeling afraid of the legal consequences after any incidents (Lingard and
Climate at work Rowlinson, 1994). In reality, the adequacy of this criterion depends on
Isaak et al. Safety communication None Positive how often employers record incidents of missed days due to accidents
(2016) Management
and how well workers understand their job’s legal responsibilities
commitment to safety
Procedure and safety (Jaselskis et al., 1996). Besides that, incidents are also being modified
report and underreported to influence the company’s experience modification
rating. The higher incident frequency will cause the contractor’s

5
I.S. Noor Arzahan et al.
company to pay a higher insurance premium, so the recorded incidents
are less likely to be correct. Hence, calculating this incident number is
difficult and unreliable, and using this criterion to assess safety perfor­
mance is not advised for any organization as stated by (Hinze et al.,
1995; Everett and Thompson, 1995).
In high-reliability sectors nowadays, preventative techniques are
commonly implemented. They have progressed from reactive earlier
and reached the level where all safety measures were in place and
practicing an excellent safety management system (Morrow et al.,
2014). The preventative technique also was applied in an organization
where no significant high fatalities incidents were recorded. Thus, for
low-risk organizations such as education-based as schools, training in­
stitutes, and government agencies, proactive measures are beneficial to
be used over-reactive measures. In these industries, employee behavior
observation (Ismara et al., 2019; Uzuntarla et al., 2020) and employee
participation in safety-related activities are more routinely employed as
a metric for evaluating safety performance (Mearns et al., 2003). Pro­
active measures are a safety performance evaluation instrument that has
gotten much attention in recent years because of their reliable charac­
teristics and not much controversy.
Predictive and monitoring measures of this proactive criteria, ac­
cording to Körvers and Sonnemans (2008), including indications that
are assessed before incidents happen, and the outcomes of audits, per­
ceptions of employees as to the benefits from practicing safety, and also
the workplace safety observations. Most of the studies selected in this
review comprehend safety behaviors as an indication of safety perfor­
mance in light of these inadequacies in reactive techniques for
measuring safety performance. The behavior is described as employees’
actions at work to ensure their safety and others’ safety in the working
environment. Yet, some recent studies still preferred dual measurement
of safety performance by considering both accident rates and safety
behavior. Even more interesting, Fernández-Muñiz et al., 2014 also
introduced an additional safety performance indicator by also looking at
employee satisfaction. This beneficial addition is helpful for industries
that are still in the early stage of inculcating safety culture and lower
risk.
5.4. Safety culture or climate and safety performance in healthcare – The
link
The relationship between the studied elements is shown in Table 3.
Researchers in healthcare facilities have analyzed the link between
variables in two ways. First, the fundamental analysis involved a
connection between each of the safety culture dimension elements and
safety performance metrics using correlation coefficients and bivariate
test analysis (the non-intermediate link between variables). Second,
the connection between safety culture or safety climate as a single
structure towards safety performance. This analysis is a higher-level
analysis involving structural equations and the presence of mediator
or moderator variables. This review also considers any other elements or
factors that might contribute to, influence, or enhance the organiza­
tion’s safety performance, thus conducting a more thorough examina­
tion of the reasons for the incident events. This review also contributes
to an additional finding in the mediators or moderators linking safety
culture to safety performance.
The second method looked at the link between safety climate or
culture and the proactive safety performance measures such as safety
compliance and involvement. These two criteria provide an assumption
on workplace accidents tendency based on individual perception or
psychosocial factors. Numerous researches have been conducted to
determine their effects and between these studied variables (Abdullah
et al., 2016; Ali et al., 2009; Kasim et al., 2019; Mat et al., 2016). Based
on the analysis, safety climate or culture may be recognized as a reliable
indicator of safety performance since it predicts safety behavior.
Workers’ perceptions of the organization’s safety rules, beliefs, and
values are indicators of the safety culture or climate. This perception
6
Safety Science 147 (2022) 105624
connects to people’s drive to execute their jobs that impact safety be­
haviors and incidents. The justification of the pathway has been
described in a study by Lingard et al. (2012). Management commitment
to safety affects worker injury performance by fostering shared views of
their immediate superiors’ safety requirements. Supervisors serve as a
“conduit” for communicating corporate safety objectives to front-line
employees and offering critical feedback on their conduct’s appropri­
ateness (Niskanen, 1994) The relationship between safety commitment
at the top of the organization and the incidence of injuries in workgroups
was completely mediated by supervisors’ expectations for safety.
From the statistical test results, the link between variables is avail­
able in two options. First, a negative correlation exists between safety
culture or climate and reactive safety performance metrics. Second,
there is a significant correlation between safety culture or climate and
proactive safety performance metrics. Looking through the literature,
the kind of criteria to choose is determined by the industry standard.
According to the findings, the riskier organizations such as aviation,
construction, and oil and gas, would prefer reactive criteria and find it
more appropriate because of changing working conditions (Siti Fatimah
Bahari, 2011; Amirah et al., 2013; Abdullah , 2016), but proactive in­
terventions are more appropriate in low-risk industries, such as
healthcare, due to the consistency of conditions and habits across time.
Finally, none of the assessed articles included studies examining the
effect of safety interventions on changes in safety performance. Perhaps,
this is because safety culture involves human belief, intention, motiva­
tion, and competence, which is the effort in the long run. However, most
research has proposed that safety climate and safety culture elements
that are proven statistically work on safety improvements to be included
as interventional factors in future studies.
6. Limitation
First, we were only able to find a few research on the relationship
between the studied variables in the healthcare industry. As a result,
finding a larger number of high-quality research in this sector is chal­
lenging. Despite doing a thorough literature search across five online
databases and using broad keywords, we could not rule out the possi­
bility of missing some relevant papers.
7. Conclusion
Finally, this review looks at papers on the effects of safety climate
and culture on safety performance. The relevance of analyzing safety
performance has been verified in recent years to compare the feasibility
of safety culture practice and the impact on the target organization. Two
types of safety performance evaluations available are reactive and pro­
active measures. Reactive and proactive measures are negatively and
positively related to safety culture and safety climate, respectively,
following statistical findings. However, determining such effects is
challenging due to societies’ varying features and studied organizations.
What’s more, researchers seem to prefer proactive approaches that
promote ease of use and a preventive strategy, particularly in healthcare
settings. The limited research that has been conducted on the connection
between reactive and proactive measures, with safety culture and safety
climate, has discovered that safety compliance is more dependable.
However, researchers support future studies to include safety satisfac­
tion as an additional safety measure. This measure will reflect positive
morale and higher safety awareness to comply with the excellent safety
management system. The findings also revealed that characteristics such
as safety competence that include good safety knowledge might mod­
erate the effects of safety culture and safety climate on safety
performance.
8. Statement on the accessibility of data
The article/supplementary material contains the study’s original
I.S. Noor Arzahan et al.
contributions. Additional questions should be addressed to the corre­
sponding author(s).
9. Contributions of the authors
ISNA planned the research, conducted the literature review, evalu­
ated the quality of the literature, and wrote the paper. ZI and SMY
drafted an article outline, conducted a literature study, evaluated the
quality of the literature, then edited and polished the paper. Each author
contributed to the paper and approved the final version submitted for
publication.
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.
Acknowledgement
This study was supported by the Universiti Teknologi Mara Malaysia
(UiTM) under UiTM Grant No. 600-RMC/GPK 5/3 (205/2020).
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